CHC Study Guide 2026

A benefit explanation (Explanation of Benefits or EOB) details the financial aspects of healthcare services, including services rendered, dates, charges, and insurer payments. Its purpose is financial transparency regarding claims, not to provide clinical information, so a patient's comprehensive medical history is typically omitted.

The chargemaster is the hospital's master price list containing every billable item with associated codes and charges, forming the basis for all claims submitted to payers.

The Social Security Act prohibits federal healthcare programs from paying for services rendered by excluded individuals, making pre-hire exclusion screening a compliance necessity.

Compliance policies and procedures are not static documents. An essential component of an effective compliance program is to have a system in place for their periodic (at least annual) review and update. This ensures they remain current with changing laws, regulations, and the organization's own operational realities.

The Summary Plan Description (SPD) is a crucial document required by ERISA that provides participants with an easy-to-understand summary of their health plan's benefits, rights, and responsibilities. Plan administrators must provide this document to new participants within 90 days of them becoming covered by the plan. It serves as the primary source of information for participants about their plan.

The Stark Law is more narrowly focused than the AKS. It specifically prohibits physicians from referring Medicare or Medicaid patients for 'designated health services' to entities with which they (or an immediate family member) have a financial relationship, unless an exception applies. The AKS applies more broadly to any remuneration for referrals of any federal healthcare business and is not limited to physicians or DHS.