Claims Processing and Reimbursement Flashcards
6 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 6 Claims Processing and Reimbursement flashcards as text
What is a remittance advice and how is it used in revenue cycle?
Answer: A document from the payer that explains how a claim was adjudicated including payments adjustments and denials
The remittance advice details how each submitted claim was processed enabling accurate payment posting and denial identification.
Under Medicare's Inpatient Prospective Payment System, what drives the payment amount for an inpatient admission?
Answer: The Diagnosis-Related Group assigned to the admission based on diagnoses and procedures
DRGs are payment classifications that group inpatient admissions with similar clinical characteristics into a single payment amount.
What is a contractual adjustment in healthcare billing?
Answer: The difference between the provider's billed charge and the payer's contracted allowed amount which is written off
Contractual adjustments reduce the billed charge to the agreed-upon allowed amount per the provider's contract with the payer.
What does balance billing mean and when is it prohibited?
Answer: Billing a patient for amounts above the contracted rate which is prohibited in-network under most contracts and federal surprise billing laws
Balance billing charges patients the difference between the provider's billed charge and the payer's allowed amount which in-network providers are contractually prohibited from doing.
What is the purpose of a clearinghouse in electronic claims submission?
Answer: To translate and validate claims before forwarding them to payers reducing rejection rates
Clearinghouses act as intermediaries between providers and payers translating claims into payer-specific formats and catching errors before submission.
What is the significance of the allowed amount in health insurance reimbursement?
Answer: The maximum amount the insurer will pay for a specific service based on the contracted rate or fee schedule
The allowed amount is the fee schedule or contracted rate that determines how the payer calculates its payment and the patient's cost-sharing.