Claims Processing and Billing Flashcards
7 cards from real CRCR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Claims Processing and Billing flashcards as text
What does 'coordination of benefits' (COB) determine in the claims billing process?
Answer: The order in which multiple insurers pay claims when a patient has more than one insurance plan
COB rules establish which insurer pays first (primary) and which pays second (secondary) when a patient has coverage under multiple plans.
A claim is submitted with an incorrect patient date of birth. The claim is rejected. What type of rejection is this?
Answer: Administrative or demographic rejection
Incorrect demographic information such as date of birth results in an administrative or demographic rejection because the patient cannot be identified.
Which federal law sets the standard electronic transaction formats for healthcare claims, including the HIPAA 837 transaction set?
Answer: The Health Insurance Portability and Accountability Act (HIPAA)
HIPAA established standardized electronic transaction formats, including the 837P and 837I for professional and institutional claims, respectively.
A skilled nursing facility (SNF) bills Medicare under the Prospective Payment System (PPS). What is the payment unit for SNF PPS?
Answer: Per diem (daily rate) based on Resource Utilization Groups (RUGs)
Medicare SNF PPS pays a per diem rate based on the patient's Resource Utilization Group (RUG) category, which reflects the level of care needed.
A payer issues an Explanation of Benefits (EOB) showing a 'contractual adjustment.' What does this mean for the provider?
Answer: The provider must write off the difference between billed charges and the contracted allowable as a contractual adjustment and cannot bill the patient for it
A contractual adjustment represents the difference between the provider's billed charges and the contracted rate, which the provider agrees to write off per their payer contract.
What is the primary purpose of a charge master (chargemaster) in hospital billing?
Answer: To serve as a comprehensive list of all services, supplies, and procedures a hospital provides along with their standard charges and associated billing codes
The charge master (CDM) is a hospital's master list of all billable items with their standard charges and corresponding procedure/revenue codes used for billing.
Under the False Claims Act, what is the term for a private individual who files a lawsuit on behalf of the government against a provider committing fraud?
Answer: Qui tam relator (whistleblower)
A qui tam relator is a private individual, often an insider, who files a lawsuit under the False Claims Act on the government's behalf and may receive a share of recovered funds.