CMRT Revenue Cycle Management 3 — Questions and Answers
Question 1: What is the primary purpose of a clearinghouse in the revenue cycle?
- To adjudicate claims and issue payment
- To translate and validate claims before forwarding them to payers (Correct answer)
- To collect patient copayments at the point of service
- To generate the explanation of benefits for patients
Correct answer: To translate and validate claims before forwarding them to payers
A clearinghouse serves as an intermediary that checks claims for errors and reformats them to meet each payer's specific requirements.
Question 2: Which denial reason code category under CARC indicates that the service was not covered under the patient's benefit plan?
- CO (Contractual Obligation)
- PR (Patient Responsibility)
- OA (Other Adjustment) (Correct answer)
- PI (Payer Initiated Reductions)
Correct answer: OA (Other Adjustment)
OA (Other Adjustment) codes are used when the adjustment does not fit contractual obligation or patient responsibility categories, including non-covered benefits.
Question 3: A provider's net collection rate is 94%. What does the remaining 6% most likely represent?
- Claims still in process with the payer
- Adjustments, write-offs, and uncollectable amounts (Correct answer)
- Patient balances pending statement issuance
- Claims submitted to secondary insurance
Correct answer: Adjustments, write-offs, and uncollectable amounts
The net collection rate measures the percentage of collectible revenue actually collected; the remainder consists of bad debt, contractual adjustments, and write-offs.
Question 4: Which document initiated by the payer informs the provider of how a claim was adjudicated and any payment made?
- Remittance advice (ERA/EOB) (Correct answer)
- Advance Beneficiary Notice (ABN)
- Coordination of Benefits form
- Certificate of Medical Necessity
Correct answer: Remittance advice (ERA/EOB)
The remittance advice (electronic ERA or paper EOB) details claim adjudication decisions, payment amounts, and adjustment reason codes.
Question 5: In the context of revenue cycle management, what is 'charge capture'?
- Recording all billable services rendered during a patient encounter (Correct answer)
- Collecting patient out-of-pocket payments at discharge
- Submitting charges to the state Medicaid office
- Auditing charts to detect upcoding
Correct answer: Recording all billable services rendered during a patient encounter
Charge capture is the process of recording every billable service, procedure, and supply provided so it can be translated into billable codes.
Question 6: A payer requests additional clinical documentation to support a submitted claim. This request is called a(n):
- Remittance advisory
- Additional development request (ADR) (Correct answer)
- Coordination of benefits inquiry
- Advance beneficiary notice
Correct answer: Additional development request (ADR)
An ADR (Additional Development Request) is sent by a payer, often Medicare, when more documentation is needed to process or audit a claim.
Question 7: Which of the following would most likely cause a claim to be denied for 'timely filing'?
- Submitting a claim within 30 days of service for a Medicaid patient
- Submitting a claim after the payer's contractual deadline has passed (Correct answer)
- Filing a corrected claim without a correction indicator
- Using an outdated fee schedule
Correct answer: Submitting a claim after the payer's contractual deadline has passed
Timely filing denials occur when a claim is submitted after the payer's contractual or regulatory deadline, which varies by payer.
CMRT Revenue Cycle Management 3
What is the primary purpose of a clearinghouse in the revenue cycle?