Claims Processing and Reimbursement 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 Reimbursement flashcards as text
A claim is denied because the procedure code is inconsistent with the patient's gender. What type of edit triggered this denial?
Answer: Gender-specific edit
Gender-specific edits flag procedures that are anatomically impossible or inappropriate for the reported patient gender.
Which Medicare claim form is used by institutional providers such as hospitals and skilled nursing facilities?
Answer: UB-04 (CMS-1450)
The UB-04 (CMS-1450) is the standard institutional claim form used by hospitals, SNFs, and other facility providers.
A payer applies a coordination of benefits (COB) adjustment and pays only $150 of a $400 allowed amount because another plan paid $250. This COB method is called:
Answer: Non-duplication method
Under the non-duplication method, the secondary payer pays nothing if the primary payer's payment equals or exceeds the secondary plan's allowable amount.
What is the purpose of the National Uniform Billing Committee (NUBC)?
Answer: To maintain and update the UB-04 data set and billing standards
The NUBC maintains the UB-04 claim form data set and establishes uniform billing standards for institutional healthcare providers.
A hospital submits a claim for an inpatient stay but failed to obtain pre-authorization. The payer denies the claim as 'not medically necessary.' What is the best first step?
Answer: Appeal the denial with clinical documentation supporting medical necessity
Appealing with supporting clinical documentation is the appropriate first step to challenge a medical necessity denial.
Which of the following describes 'split billing'?
Answer: Separating a claim by date of service across two billing periods
Split billing involves dividing a claim across billing periods, often at month-end, to ensure all services within a period are captured correctly.
Under the Medicare Outpatient Prospective Payment System (OPPS), what are Ambulatory Payment Classifications (APCs)?
Answer: Payment groups for outpatient services with similar clinical and resource characteristics
APCs are Medicare's payment groups for outpatient hospital services, where services with similar clinical characteristics and resource use are grouped together for a fixed payment.