CPCA Reimbursement and Payer Policies Flashcards
6 cards from real CPCA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CPCA Reimbursement and Payer Policies flashcards as text
Which Medicare form must a provider give a patient before performing a non-covered service so the patient can be billed out-of-pocket?
Answer: ABN (Advance Beneficiary Notice)
An ABN notifies the Medicare beneficiary that the service may not be covered and that they will be responsible for payment.
When a payer bundles two separately billed services into one payment, what edit system is typically responsible?
Answer: NCCI (National Correct Coding Initiative) edits
NCCI edits are CMS-developed code pairs that prevent inappropriate billing of two codes that should not be reported together.
A cosmetic dermatology practice bills a procedure that is explicitly excluded from coverage. What is the best course of action?
Answer: Collect full payment directly from the patient before service
For services that are explicitly excluded from insurance coverage, collecting direct patient payment before service is appropriate and legally sound.
What is a 'clean claim' in medical billing?
Answer: A claim with all required information to be processed without additional information requests
A clean claim contains all required fields and information needed for the payer to adjudicate it without delay or additional requests.
Which of the following best describes a 'write-off' in medical billing?
Answer: The amount the provider agrees not to collect as part of a contractual agreement
A write-off is the contractual adjustment a provider accepts as part of their agreement with an insurance payer, reducing the billed amount to the allowed amount.
What is the purpose of the National Provider Identifier (NPI) on a claim form?
Answer: To uniquely identify the healthcare provider billing for services
The NPI is a 10-digit unique identifier assigned to healthcare providers for use in standard HIPAA transactions including claims.