CRCR CRCR - Certified Revenue Cycle Representative Program Payment Posting and Reconciliation Questions and Answers 2 — Questions and Answers
Question 1: Which HIPAA transaction set is used for electronic claim submission to payers?
- HIPAA 837 (Correct answer)
- HIPAA 835
- HIPAA 270/271
- HIPAA 276/277
Correct answer: HIPAA 837
The HIPAA 837 transaction is the standard electronic format for submitting professional (837P), institutional (837I), and dental (837D) claims to payers.
Question 2: What is the difference between a 'payment variance' and a 'contractual adjustment' in payment reconciliation?
- They are identical terms used interchangeably
- A payment variance is an unexpected difference between expected and received payment; a contractual adjustment is the agreed write-off per contract (Correct answer)
- A contractual adjustment is always larger than a payment variance
- A payment variance applies only to Medicare claims
Correct answer: A payment variance is an unexpected difference between expected and received payment; a contractual adjustment is the agreed write-off per contract
A contractual adjustment is the anticipated write-off per contract terms, while a payment variance is an unanticipated discrepancy between expected and actual payment that requires investigation.
Question 3: What is a 'zero-pay' remittance in payment posting?
- A remittance where the payer paid the full billed amount
- A remittance where the payer processed the claim but issued no payment, often due to the patient's deductible (Correct answer)
- A remittance indicating a duplicate claim was voided
- A remittance for services not yet rendered
Correct answer: A remittance where the payer processed the claim but issued no payment, often due to the patient's deductible
A zero-pay remittance means the payer adjudicated the claim but applied the entire allowed amount to the patient's deductible or other patient responsibility, resulting in no payment to the provider.
Question 4: In payment reconciliation, what does it mean to 'balance a batch'?
- To verify that total payments posted equal the total received per the deposit (Correct answer)
- To match the number of claims submitted to claims paid
- To confirm patient demographic information matches payer records
- To reconcile the charge master with payer fee schedules
Correct answer: To verify that total payments posted equal the total received per the deposit
Balancing a batch ensures the total dollar amount of payments posted in the billing system matches the actual bank deposit amount for that batch, preventing posting errors.
Question 5: What is a 'take-back' or 'recoupment' by a payer?
- A patient's request to cancel a scheduled payment plan
- A payer's action to recover previously paid amounts it believes were overpaid or paid in error (Correct answer)
- A provider's request for additional payment after initial adjudication
- A secondary payer's refusal to pay a claim
Correct answer: A payer's action to recover previously paid amounts it believes were overpaid or paid in error
A recoupment or take-back occurs when a payer offsets future payments or requests a refund to recover amounts it has determined were overpaid on prior claims.
Question 6: What is the significance of the CARC (Claim Adjustment Reason Code) on an ERA?
- It identifies the rendering provider's specialty
- It explains why a payment was adjusted or denied on a specific service line (Correct answer)
- It indicates the patient's plan deductible amount
- It specifies the payer's timely filing limit
Correct answer: It explains why a payment was adjusted or denied on a specific service line
Claim Adjustment Reason Codes (CARCs) are standardized codes on the ERA that explain why a claim was adjusted, reduced, or denied, guiding follow-up and appeal decisions.
CRCR CRCR - Certified Revenue Cycle Representative Program Payment Posting and Reconciliation Questions and Answers 2
Which HIPAA transaction set is used for electronic claim submission to payers?