CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing Questions and Answers — Questions and Answers
Question 1: A hospital billing department submits a batch of claims to a third-party entity that reviews the claims for errors, standardizes the data into the HIPAA-compliant format, and then routes them to the appropriate insurance payers. What is this third-party entity called?
- Revenue Cycle Management Vendor
- Payer Adjudicator
- Healthcare Clearinghouse (Correct answer)
- Third-Party Administrator (TPA)
Correct answer: Healthcare Clearinghouse
A healthcare clearinghouse acts as an intermediary between healthcare providers and payers. Its primary functions are to receive claims, check them for errors (a process called 'scrubbing'), convert them into a standard electronic format (like ANSI X12 837), and then transmit the clean claims to the correct payers.
Question 2: A patient receives a document from their insurance company that details the services billed by the provider, the amount covered by insurance, and the remaining balance the patient is responsible for. This document is not a bill. Which of the following is it?
- Electronic Remittance Advice (ERA)
- Explanation of Benefits (EOB) (Correct answer)
- Advance Beneficiary Notice (ABN)
- Coordination of Benefits (COB) form
Correct answer: Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a statement sent from the insurance company to the patient. It explains what medical treatments and/or services were paid for on their behalf. It is not a bill. An Electronic Remittance Advice (ERA) contains similar payment information but is sent electronically from the payer to the provider.
Question 3: A clinic uses software to automatically review outpatient claims for missing diagnosis codes, incorrect patient demographic information, and potential unbundling issues before they are sent to the payer. What is this automated review process known as?
- Adjudication
- Claim Scrubbing (Correct answer)
- Eligibility Verification
- Remittance Posting
Correct answer: Claim Scrubbing
Claim scrubbing is the process of reviewing a claim to check for errors and ensure it meets payer-specific requirements and formatting guidelines before submission. This process helps to increase the clean claim rate, reduce denials, and accelerate reimbursement.
Question 4: A claim is denied with a Claim Adjustment Reason Code (CARC) of CO-29. What is the most likely reason for this denial?
- The service is a non-covered charge.
- The claim is a duplicate of one already processed.
- The patient's coverage was terminated.
- The claim was submitted after the payer's filing deadline. (Correct answer)
Correct answer: The claim was submitted after the payer's filing deadline.
The denial code CO-29 specifically indicates that the time limit for filing the claim has expired. Payers have specific timely filing limits, and claims submitted after this window will be denied.
Question 5: A patient is seen by their primary care physician for a follow-up visit. Which standard claim form would be used to bill for the physician's professional services?
- UB-04 (CMS-1450)
- CMS-1500 (HCFA-1500) (Correct answer)
- Advance Beneficiary Notice (ABN)
- Explanation of Benefits (EOB)
Correct answer: CMS-1500 (HCFA-1500)
The CMS-1500 form is the standard claim form used by individual healthcare providers, such as physicians and other professionals, to bill for their services. The UB-04 form is used by institutional facilities, like hospitals and skilled nursing facilities, to bill for their services (facility fees, room and board, etc.).
Question 6: After a payer processes a batch of claims, it sends a single electronic file to the hospital's billing system that provides payment and adjustment details for multiple patients. This file allows for automated posting of payments to patient accounts. What is this file called?
- Electronic Data Interchange (EDI)
- Explanation of Benefits (EOB)
- Claim Status Report
- Electronic Remittance Advice (ERA) (Correct answer)
Correct answer: Electronic Remittance Advice (ERA)
An Electronic Remittance Advice (ERA), often in the HIPAA-standard 835 file format, is an electronic document sent by payers to providers. It explains how claims were paid or denied and provides details on adjustments, allowing for efficient, automated posting of payments and denials into the provider's system.
CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing Questions and Answers
A hospital billing department submits a batch of claims to a third-party entity that reviews the claims for errors, standardizes the data into the HIPAA-compliant format, and then routes them to the appropriate insurance payers.
What is this third-party entity called?