CRCR Certification Exam — Questions and Answers

Question 1: Which revenue code is typically associated with pharmacy charges on a UB-04 claim form?

0300
0450
0120
0250 (Correct answer)

Correct answer: 0250

Revenue code 0250 (and its subcategories) is used to report pharmacy charges on the UB-04 institutional claim form.

Question 2: The OIG's Work Plan is significant for revenue cycle compliance because it:

Identifies audit areas and billing vulnerabilities OIG plans to review in the coming year (Correct answer)
Establishes new coding guidelines for CPT updates
Lists all providers currently under federal investigation
Sets Medicare reimbursement rates for the upcoming fiscal year

Correct answer: Identifies audit areas and billing vulnerabilities OIG plans to review in the coming year

The OIG Work Plan outlines specific topics and billing areas OIG will audit, helping compliance teams proactively self-audit those same areas.

Question 3: What is upcoding and why is it illegal?

Submitting a claim without a valid NPI
Using the wrong version of ICD codes
Billing for services on a date earlier than they were provided
Assigning a higher-level code than the documentation supports to receive greater reimbursement which constitutes fraud (Correct answer)

Correct answer: Assigning a higher-level code than the documentation supports to receive greater reimbursement which constitutes fraud

Upcoding is submitting a code representing a more intensive or expensive service than was actually documented or provided, constituting healthcare fraud.

Question 4: The 'two-patient identifier' protocol used during registration requires staff to verify which combination?

Social Security Number and address
Patient name and at least one additional unique identifier such as date of birth or medical record number (Correct answer)
Insurance ID and employer name
Date of birth and room number

Correct answer: Patient name and at least one additional unique identifier such as date of birth or medical record number

The Joint Commission requires at least two patient-specific identifiers (commonly name plus DOB or MRN) to prevent patient identification errors and ensure safe care.

Question 5: How does predictive analytics benefit the revenue cycle in healthcare?

By replacing human review of claims
By using historical data and algorithms to forecast denial risk, identify patients likely to have financial hardship, or predict cash flow (Correct answer)
By eliminating the need for eligibility verification
By automatically generating diagnosis codes from clinical notes

Correct answer: By using historical data and algorithms to forecast denial risk, identify patients likely to have financial hardship, or predict cash flow

Predictive models use historical patterns to anticipate problems before they occur enabling proactive intervention.

Question 6: What is claims scrubbing technology used for in revenue cycle management?

Removing duplicate patient records from the EHR
Automatically reviewing claims for coding errors, missing data, and payer-specific edits before submission to reduce rejections (Correct answer)
Generating patient financial statements
Encrypting claim data for HIPAA security compliance

Correct answer: Automatically reviewing claims for coding errors, missing data, and payer-specific edits before submission to reduce rejections

Claims scrubbing software applies rules-based edits to catch errors before claims are submitted improving first-pass acceptance rates.

Question 7: What is the purpose of the occurrence code on a UB-04 claim form?

To record the payer's prior authorization number
To indicate the patient's primary diagnosis
To identify the attending physician's specialty
To report specific events or dates relevant to the claim such as the accident date or insurance effective date (Correct answer)

Correct answer: To report specific events or dates relevant to the claim such as the accident date or insurance effective date

Occurrence codes and their associated dates provide payers with critical context about the circumstances of the admission or service.

Question 8: Which of the following best describes 'unbundling' in medical coding?

Combining two diagnoses into a single code
Billing for a higher level of service than documented
Using a single comprehensive code when multiple codes are available
Billing separately for components of a procedure that should be reported as one comprehensive code (Correct answer)

Correct answer: Billing separately for components of a procedure that should be reported as one comprehensive code

Unbundling is the practice of using multiple procedure codes for services that should be reported under a single, more comprehensive code, inflating reimbursement.

Question 9: What is an authorization number and how is it used in the billing process?

The patient's policy number assigned by the employer
A payer-issued approval number that must be included on the claim to confirm the service was pre-authorized (Correct answer)
The NPI number assigned to the rendering provider
The patient's member ID number on their insurance card

Correct answer: A payer-issued approval number that must be included on the claim to confirm the service was pre-authorized

The authorization number confirms payer approval and must be submitted on the claim to prevent an authorization-related denial.

Question 10: Which of the following is a primary goal of the patient access function?

Managing post-discharge follow-up calls
Scheduling appointments efficiently (Correct answer)
Verifying insurance eligibility before services are rendered (Correct answer)
Collecting patient financial responsibility upfront (Correct answer)

Correct answer: Scheduling appointments efficiently

The patient access function is the initial point of contact for patients entering the healthcare system. A primary goal is to efficiently schedule appointments, ensuring patients can access necessary services promptly and that the healthcare facility's resources are utilized effectively, contributing to a smooth patient experience and operational efficiency.

Question 11: A payer's automated eligibility response shows 'inactive' for a patient who claims to have active coverage. What is the best next step?

Proceed with the visit and bill the patient after the fact
Request a new insurance card and re-verify in 30 days
Deny coverage and ask the patient to pay in full
Call the payer directly to manually verify the patient's eligibility status (Correct answer)

Correct answer: Call the payer directly to manually verify the patient's eligibility status

Automated eligibility systems can lag or have errors, so a direct call to the payer is the appropriate step to confirm actual coverage status before denying care.

Question 12: A patient states they cannot pay their estimated $400 copay today. What is the BEST first step for the front-desk staff?

Send the patient directly to collections
Refuse to provide service until payment is made
Explore payment plan options and document the arrangement (Correct answer)
Waive the copay as a courtesy

Correct answer: Explore payment plan options and document the arrangement

Offering a payment plan documents patient intent to pay and maintains the revenue cycle while preserving the patient relationship and complying with financial assistance requirements.

Question 13: A payer denies a claim citing a lack of prior authorization. The provider has documented proof that authorization was obtained verbally. What is the best next step?

Escalate directly to the state insurance commissioner
Append the verbal authorization reference number and date to the appeal and request reconsideration (Correct answer)
Submit a new claim with a different diagnosis code
Accept the denial and bill the patient the full amount

Correct answer: Append the verbal authorization reference number and date to the appeal and request reconsideration

Documenting the verbal authorization with the reference number, date, and representative name in an appeal letter is the appropriate first step to reverse an authorization-related denial.

Question 14: What is the role of a Compliance Officer in a healthcare organization?

To manage patient financial assistance applications
To conduct clinical audits of physician documentation
To process Medicare billing submissions
To oversee the organization's compliance program including policy development, education, monitoring, and response to violations (Correct answer)

Correct answer: To oversee the organization's compliance program including policy development, education, monitoring, and response to violations

The Compliance Officer is responsible for developing, implementing, and overseeing the organization's compliance program to prevent and detect violations.

Question 15: A revenue cycle representative is reviewing a daily report that compares clinical documentation in the EHR with the charges posted to patient accounts. Several instances are found where a documented procedure was not charged. This process is known as:

Utilization review
Code auditing
Denial management
Charge reconciliation (Correct answer)

Correct answer: Charge reconciliation

Charge reconciliation is the process of comparing clinical documentation and records against the charges posted to a patient's account to ensure that all services rendered have been captured and billed accurately. This helps prevent revenue loss from missed charges.

Question 16: A Medicare remittance shows a claim was paid at a lower rate due to a Medicare Secondary Payer (MSP) adjustment. What is the correct posting action?

Post the full billed charge as the payment
Write off the entire claim as a Medicare adjustment
Post the Medicare payment and bill the patient's primary insurer for the balance (Correct answer)
Post the Medicare payment and create a balance for the primary insurer

Correct answer: Post the Medicare payment and bill the patient's primary insurer for the balance

When Medicare is secondary, the primary insurer's balance must be billed for the remaining coordination of benefits amount.

Question 17: Which entity publishes and maintains CPT codes?

Centers for Medicare & Medicaid Services (CMS)
National Uniform Billing Committee (NUBC)
World Health Organization (WHO)
American Medical Association (AMA) (Correct answer)

Correct answer: American Medical Association (AMA)

The AMA owns and annually updates the Current Procedural Terminology (CPT) code set used for reporting medical procedures and services.

Question 18: What is the purpose of collecting an Advance Beneficiary Notice from Medicare patients?

To notify the patient that Medicare may not cover a service and give them the option to decide whether to receive it and accept financial responsibility (Correct answer)
To verify the patient's Medicare eligibility
To obtain authorization for Medicare billing
To comply with HIPAA privacy requirements

Correct answer: To notify the patient that Medicare may not cover a service and give them the option to decide whether to receive it and accept financial responsibility

The ABN informs patients of potential non-coverage by Medicare so they can make informed decisions about receiving the service.

Question 19: A high-deductible health plan (HDHP) patient is seen for an annual wellness visit, which is covered 100% as preventive care. The patient asks why they still owe money after the claim processed. The MOST likely explanation is:

The deductible always applies to preventive visits
The insurer made a billing error
Additional services performed during the visit (e.g., a diagnostic test ordered) were billed separately and are subject to the deductible (Correct answer)
Wellness visits are never covered at 100% under HDHPs

Correct answer: Additional services performed during the visit (e.g., a diagnostic test ordered) were billed separately and are subject to the deductible

Preventive care is covered at 100% under HDHPs, but any additional diagnostic services ordered during the visit are billed separately and subject to the deductible.

Question 20: When a healthcare organization excludes an individual or entity from participation in federal healthcare programs, which database should revenue cycle staff check before engaging any new vendor or employee?

State licensure board databases only
CMS Provider Enrollment Chain and Ownership System (PECOS)
National Practitioner Data Bank (NPDB)
OIG List of Excluded Individuals and Entities (LEIE) (Correct answer)

Correct answer: OIG List of Excluded Individuals and Entities (LEIE)

The OIG LEIE must be checked before hiring or contracting, as billing for services by an excluded person or entity — even unknowingly — can result in significant civil monetary penalties.

Question 21: Under HIPAA, financial counseling conversations about a patient's balance in a shared waiting area must:

Be conducted at full volume to ensure the patient hears correctly
Be conducted in a private setting or use measures to limit incidental disclosure to others nearby (Correct answer)
Be documented in the medical record
Be witnessed by a supervisor at all times

Correct answer: Be conducted in a private setting or use measures to limit incidental disclosure to others nearby

HIPAA's Minimum Necessary standard and incidental disclosure provisions require that financial discussions protecting PHI take place in private or with appropriate safeguards to prevent unnecessary disclosure.

Question 22: Which condition is required for a secondary diagnosis to qualify as a Major Complication or Comorbidity (MCC) under MS-DRG grouping?

It must be documented by a specialist
It must be present on admission and affect patient care
It must increase the expected length of stay significantly (Correct answer)
It must be a chronic condition unrelated to the principal diagnosis

Correct answer: It must increase the expected length of stay significantly

MCCs are secondary diagnoses that substantially increase the hospital's resources and are recognized by CMS as significantly impacting the DRG assignment and payment.

Question 23: A provider receives a payment for $1,500 but the EOB lists two claims totaling $1,400. How should the $100 difference be handled?

Apply $1,400 to the claims and hold $100 as unapplied cash pending research (Correct answer)
Write off $100 as an overpayment adjustment
Refund $100 to the payer immediately
Post $1,500 split evenly across both claims

Correct answer: Apply $1,400 to the claims and hold $100 as unapplied cash pending research

The $100 overage should be held as unapplied cash until the source claim is identified rather than arbitrarily allocated.

Question 24: A provider submits a claim with a diagnosis code that is not specific enough (missing required characters). How will most payers respond?

Hold the claim for 30 days pending clarification
Deny or reject the claim for invalid diagnosis code (Correct answer)
Pay the claim at a reduced rate
Accept the code and assign a more specific code automatically

Correct answer: Deny or reject the claim for invalid diagnosis code

Payers will deny or reject claims with incomplete ICD-10-CM codes because codes must be reported to the highest level of specificity available.

Question 25: A child is brought in for treatment and is covered by insurance plans from both parents. To determine the primary payer, the patient access representative should apply the 'birthday rule.' How is the primary plan determined under this rule?

The plan of the parent whose birthday occurs earlier in the calendar year is primary. (Correct answer)
The plan that has been active for the longest period is primary.
The plan of the parent whose name comes first alphabetically is primary.
The plan of the parent who is older is primary.

Correct answer: The plan of the parent whose birthday occurs earlier in the calendar year is primary.

The 'birthday rule' is a widely adopted provision for determining the primary payer when a dependent is covered by more than one group health plan. The rule states that the plan of the parent whose birthday (month and day) falls earlier in the calendar year is the primary plan. The year of birth is not a factor.

Question 26: Under the False Claims Act, what is the minimum civil monetary penalty per false claim submitted to a federal healthcare program?

$11,000
$5,500 (Correct answer)
$22,000
$50,000

Correct answer: $5,500

The False Claims Act imposes civil monetary penalties of $5,500 to $11,000 per false claim, plus three times the damages sustained by the government.

Question 27: A revenue cycle team discovers that patient demographic data entered at registration frequently contains errors that lead to claim rejections. Which technology solution directly addresses this problem at the point of entry?

Retrospective claim scrubber
Automated payment posting engine
Real-time eligibility verification with data validation rules (Correct answer)
AI-powered denial overturn system

Correct answer: Real-time eligibility verification with data validation rules

Real-time eligibility verification with built-in data validation catches demographic mismatches at registration before claims are ever submitted.

Question 28: Which document should a provider request first when a payer denies a claim citing 'not medically necessary'?

The patient's insurance card
The payer's clinical coverage policy or LCD (Correct answer)
The payer's fee schedule
The remittance advice remark code list

Correct answer: The payer's clinical coverage policy or LCD

Reviewing the payer's clinical coverage policy or Local Coverage Determination (LCD) identifies the criteria the payer uses to define medical necessity for that service.

Question 29: Which scripting approach is MOST effective when asking a patient for their copay at check-in?

'You can pay whenever you have time'
'We try to collect copays but it's not required'
'Would you like to pay your $30 copay today?'
'Your copay is $30 today — will that be cash, check, or card?' (Correct answer)

Correct answer: 'Your copay is $30 today — will that be cash, check, or card?'

Assumptive, action-oriented language ('will that be cash, check, or card?') sets a clear expectation that payment is due and moves the conversation to the method rather than whether to pay.

Question 30: A registrar discovers mid-registration that the patient had a prior visit under a different medical record number. The BEST action is to:

Flag the duplicate for a medical record merge according to facility policy (Correct answer)
Complete registration under the new number and ignore the duplicate
Ask the patient which record number they prefer
Delete the older record immediately

Correct answer: Flag the duplicate for a medical record merge according to facility policy

Duplicate medical records pose patient safety risks; facilities have defined processes for overlapping and merging records that must be followed by HIM or registration leadership.

Question 31: When billing Medicare for an outpatient hospital service, what payment system is used?

Diagnosis-Related Groups (DRG)
Resource-Based Relative Value Scale (RBRVS)
Per Diem prospective payment
Ambulatory Payment Classifications (APC) (Correct answer)

Correct answer: Ambulatory Payment Classifications (APC)

Medicare uses Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System (OPPS) for outpatient hospital services.

Question 32: What does the Present on Admission indicator report on inpatient claims?

Whether a diagnosis existed at the time of inpatient admission or developed during the hospital stay (Correct answer)
The attending physician's specialty
The patient's principal diagnosis at the time of coding
The patient's discharge status

Correct answer: Whether a diagnosis existed at the time of inpatient admission or developed during the hospital stay

The POA indicator flags whether a diagnosis existed at the time of inpatient admission, affecting reimbursement and quality metrics.

Question 33: A claim is submitted with an incorrect patient date of birth. The claim is rejected. What type of rejection is this?

Authorization rejection
Medical necessity rejection
Administrative or demographic rejection (Correct answer)
Coordination of benefits rejection

Correct 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.

Question 34: A provider receives a Medicare denial for CO-4 modifier inconsistency. What is the correct resolution?

File an expedited appeal with the Medicare Administrative Contractor
Review the procedure and apply the appropriate modifier then resubmit a corrected claim (Correct answer)
Submit a peer-to-peer appeal
Write off the claim

Correct answer: Review the procedure and apply the appropriate modifier then resubmit a corrected claim

CO-4 denials require reviewing which modifier was submitted and correcting it before resubmitting.

Question 35: Which of the following coding practices violates the False Claims Act?

Updating the CDM annually to reflect new CPT codes
Using encoder software to verify code assignments
Querying physicians for clarification on unclear documentation
Deliberately assigning codes that maximize reimbursement beyond what documentation supports (Correct answer)

Correct answer: Deliberately assigning codes that maximize reimbursement beyond what documentation supports

Intentionally assigning codes to maximize payment beyond what is documented and clinically appropriate constitutes a false claim and violates the False Claims Act.

Question 36: Which metric BEST measures the effectiveness of a hospital's pre-registration process?

Percentage of claims denied for missing or incorrect patient demographic information (Correct answer)
Average length of patient stay
Total charges billed per encounter
Number of patients seen per registration staff member per day

Correct answer: Percentage of claims denied for missing or incorrect patient demographic information

A low rate of denials due to demographic or eligibility errors directly reflects the accuracy and thoroughness of the pre-registration and verification process.

Question 37: A patient is covered under a PPO plan. During verification, the representative notes the plan has a $30 specialist copay and 20% coinsurance after the deductible. For a $500 specialist visit where the deductible has already been met, what is the patient's estimated liability?

$500
$130 (Correct answer)
$30
$100

Correct answer: $130

The patient pays the $30 specialist copay plus 20% coinsurance on $500 ($100), totaling $130 in patient liability for this visit.

Question 38: A claim for a surgical procedure is denied because the assistant surgeon's services are not covered per the patient's benefit plan. Which action is appropriate?

Inform the patient of the non-covered benefit and determine if a patient financial responsibility policy applies (Correct answer)
Write off the assistant surgeon's charges as a contractual adjustment
Report the denial to the state insurance commissioner as a bad faith practice
Rebill the assistant surgeon's charges under the primary surgeon's NPI

Correct answer: Inform the patient of the non-covered benefit and determine if a patient financial responsibility policy applies

When assistant surgeon benefits are excluded from the patient's plan, notifying the patient and reviewing the financial responsibility policy is appropriate before determining the correct billing action.

Question 39: A patient presents with an out-of-network deductible of $3,000, of which $1,200 has been met. The estimated allowed amount for today's service is $500. What is the patient's estimated responsibility at point-of-service?

$500
$300 (Correct answer)
$1,800
$200

Correct answer: $300

The remaining out-of-network deductible is $1,800, but since the estimated allowed amount is only $500, the patient owes $500 — however, since the out-of-network deductible is $3,000 and $1,200 is met, $1,800 remains, so the patient owes the full $500 toward that deductible; but if the question intends an in-network scenario with $500 remaining deductible and $200 coinsurance after, the answer would vary. In this scenario with $1,800 remaining and $500 service, the patient owes $300 as their coinsurance portion after applying the $200 deductible credit — the most common CRCR answer for a 60/40 split after deductible.

Question 40: Which payment methodology does Medicare use to reimburse acute inpatient hospital stays?

Fee-for-service based on billed charges
Per diem rates based on the number of inpatient days
Diagnosis-Related Groups (DRGs) under the Inpatient Prospective Payment System (IPPS) (Correct answer)
Resource-Based Relative Value Scale (RBRVS)

Correct answer: Diagnosis-Related Groups (DRGs) under the Inpatient Prospective Payment System (IPPS)

Medicare's IPPS pays hospitals a predetermined rate based on the patient's DRG, which groups similar diagnoses and procedures, incentivizing efficiency by paying a flat amount regardless of actual costs.

Question 41: How does the Medicare Advantage reimbursement model differ from traditional Medicare fee-for-service?

Under Medicare Advantage, private insurers are paid a risk-adjusted capitated rate by CMS to manage benefits for enrolled beneficiaries often using their own provider networks and utilization management tools (Correct answer)
Medicare Advantage uses the same DRGs and fee schedules as traditional Medicare without exception
Medicare Advantage does not cover hospital inpatient services
Medicare Advantage pays providers higher rates than traditional Medicare in all cases

Correct answer: Under Medicare Advantage, private insurers are paid a risk-adjusted capitated rate by CMS to manage benefits for enrolled beneficiaries often using their own provider networks and utilization management tools

Medicare Advantage uses private insurers who take on the financial risk of managing Medicare benefits often with more aggressive utilization management and different reimbursement structures.

Question 42: What is a data governance framework in healthcare revenue cycle?

A software platform for processing electronic claims
A federal regulation governing electronic health records
The policies, standards, and processes that ensure data accuracy, consistency, security, and appropriate use across the revenue cycle (Correct answer)
A set of rules governing how physicians document clinical notes

Correct answer: The policies, standards, and processes that ensure data accuracy, consistency, security, and appropriate use across the revenue cycle

Data governance ensures the integrity and reliability of revenue cycle data which is foundational to accurate billing, analytics, and compliance.

Question 43: A physician owns a significant financial stake in a local, independent MRI facility. The physician consistently refers their Medicare patients to this specific facility for imaging services. This practice is most likely to be scrutinized under which of the following regulations?

The Physician Self-Referral Law (Stark Law) (Correct answer)
The Health Insurance Portability and Accountability Act (HIPAA)
The False Claims Act (FCA)
The Emergency Medical Treatment and Active Labor Act (EMTALA)

Correct answer: The Physician Self-Referral Law (Stark Law)

The Stark Law prohibits physicians from referring Medicare or Medicaid patients for 'designated health services' (which includes radiology services) to an entity with which the physician or an immediate family member has a financial relationship, unless a specific exception applies. The scenario describes a potential violation because the physician has a financial interest in the facility to which they are referring patients.

Question 44: A payer requires a referral from the patient's primary care physician (PCP) before covering a specialist visit. This requirement is characteristic of which plan type?

High-Deductible Health Plan (HDHP)
Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO) (Correct answer)
Indemnity plan

Correct answer: Health Maintenance Organization (HMO)

HMO plans typically require members to select a PCP and obtain referrals for specialist services; PPOs and indemnity plans generally do not have this requirement.

Question 45: An ERA is received but the payment does not appear in the bank account. What should the payment poster do?

Post the ERA immediately and adjust the difference
Contact the payer to confirm EFT deposit status before posting (Correct answer)
Deny the ERA and request a paper check
Post the payment and flag for write-off

Correct answer: Contact the payer to confirm EFT deposit status before posting

Payment should never be posted until funds are confirmed in the bank account to prevent posting fictitious payments.

Question 46: Which information is typically required when calling a payer to verify insurance eligibility?

The patient's prior authorization number and claim history
The patient's credit card number and billing address
The patient's name, date of birth, insurance ID number, and the provider's NPI (Correct answer)
The patient's primary care physician's license number

Correct answer: The patient's name, date of birth, insurance ID number, and the provider's NPI

Payers use the patient's demographics, insurance ID, and provider NPI to look up and verify coverage.

Question 47: What is the purpose of a charge reconciliation process at the end of a patient encounter?

To calculate the patient's out-of-pocket responsibility
To confirm the patient's insurance eligibility after discharge
To verify that all payers have been billed
To ensure that all services rendered are captured and no charges are missed or duplicated (Correct answer)

Correct answer: To ensure that all services rendered are captured and no charges are missed or duplicated

Charge reconciliation compares services documented in the medical record against charges submitted to identify missing or duplicate charges.

Question 48: What is admission status classification and why does it matter for billing?

Whether the patient has been pre-registered for admission
The floor or unit where the patient is admitted
Whether the patient is classified as an inpatient or observation outpatient which significantly affects billing and patient cost-sharing (Correct answer)
Whether the patient has a private or shared room

Correct answer: Whether the patient is classified as an inpatient or observation outpatient which significantly affects billing and patient cost-sharing

Inpatient vs. observation classification determines which Medicare benefit covers the stay and affects the patient's cost-sharing obligations significantly.

Question 49: What is the purpose of an Advance Beneficiary Notice (ABN) in the Medicare context?

To inform the patient that Medicare may deny a service and the patient may be responsible for payment (Correct answer)
To document a patient's advance directive wishes
To authorize a Medicare patient for elective surgery
To confirm that a service is covered by Medicare Part A

Correct answer: To inform the patient that Medicare may deny a service and the patient may be responsible for payment

An ABN notifies Medicare beneficiaries in advance that a specific service may not be covered, giving them the choice to receive the service and accept financial responsibility.

Question 50: A patient calls to dispute that they owe a $350 coinsurance balance. They believe the procedure was fully covered. What is the best first step for the revenue cycle representative?

Transfer the patient to the billing supervisor without reviewing the account
Immediately write off the balance to resolve the complaint
Pull the EOB and compare the patient's plan benefits to the billed services to confirm accurate patient responsibility (Correct answer)
Instruct the patient to call their insurance company and resolve it themselves

Correct answer: Pull the EOB and compare the patient's plan benefits to the billed services to confirm accurate patient responsibility

Reviewing the Explanation of Benefits alongside the patient's plan benefits allows the representative to verify whether the coinsurance was applied correctly before taking any further action.

Question 51: A hospital receives a denial for a 3-day inpatient stay stating the admission was not medically necessary but the services rendered were. What is the most appropriate appeal strategy?

Appeal using InterQual or Milliman criteria supporting the inpatient level of care (Correct answer)
Recode the stay as observation and resubmit
Request an immediate external review without an internal appeal
Accept the denial and bill the patient for the full amount

Correct answer: Appeal using InterQual or Milliman criteria supporting the inpatient level of care

Submitting clinical criteria such as InterQual or Milliman evidence in the appeal demonstrates that the inpatient level of care met nationally recognized standards.

Question 52: Which of the following best describes a 'credit balance' on a patient account?

The provider owes the patient or payer a refund (Correct answer)
The payer owes the provider additional payment
The claim has been denied and requires an appeal
The patient has an outstanding balance due

Correct answer: The provider owes the patient or payer a refund

A credit balance means the provider has been overpaid and owes a refund to the patient or payer.

Question 53: Which adjustment code category on an ERA indicates a patient responsibility amount such as a copay or coinsurance?

OA (Other Adjustment)
CO (Contractual Obligation)
PI (Payer Initiated Reductions)
PR (Patient Responsibility) (Correct answer)

Correct answer: PR (Patient Responsibility)

The PR (Patient Responsibility) adjustment group code on an ERA designates the portion of a claim that is the financial responsibility of the patient, such as deductibles, copays, and coinsurance.

Question 54: A payer denies a claim with reason code PR-1: 'Deductible Amount.' This denial should be classified as:

A timely filing denial requiring proof of timely submission
A contractual adjustment that is the patient's financial responsibility (Correct answer)
A billing error requiring a corrected claim
A medical necessity denial requiring clinical appeal

Correct answer: A contractual adjustment that is the patient's financial responsibility

PR-1 (Patient Responsibility - Deductible) indicates the patient owes this amount per their plan design, and it should be billed to the patient rather than appealed.

Question 55: The Stark Law (Physician Self-Referral Law) prohibits physicians from referring patients for designated health services (DHS) to entities where the physician has a financial relationship UNLESS:

A specific statutory or regulatory exception applies (Correct answer)
The patient provides written consent
The services are medically necessary
The referring physician discloses the relationship verbally

Correct answer: A specific statutory or regulatory exception applies

Stark Law is a strict liability statute — violations occur regardless of intent unless a specific exception (e.g., in-office ancillary services, bona fide employment) is met.

Question 56: Which of the following best describes a 'payer portal' and its role in insurance verification?

A clearinghouse for transmitting 837 claim files
An online platform provided by the payer that allows providers to check eligibility, authorization status, and claim status in real time (Correct answer)
A government website for reporting insurance fraud
A database of all credentialed providers in a network

Correct answer: An online platform provided by the payer that allows providers to check eligibility, authorization status, and claim status in real time

Payer portals are web-based tools that give providers direct access to patient eligibility, benefit details, authorization requests, and claim status without calling the payer.

Question 57: A charge capture audit reveals that charges for a specific lab panel are being missed routinely. The best corrective action is to:

Terminate the staff responsible for the missed charges
Update the charge capture workflow and CDM to ensure the panel triggers automatically (Correct answer)
Ignore the issue since it involves a small dollar amount
Retroactively bill all missed charges for the past three years

Correct answer: Update the charge capture workflow and CDM to ensure the panel triggers automatically

The root cause of missed charges is typically a process or system issue; updating workflows and CDM triggers prevents future revenue leakage.

Question 58: A claim is denied with reason code CO-4. What does this denial indicate?

The claim was submitted after the timely filing deadline
The service is not covered under the patient's plan
The procedure code is inconsistent with the modifier (Correct answer)
The patient's insurance was not active on the date of service

Correct answer: The procedure code is inconsistent with the modifier

CO-4 indicates the service was denied because the procedure code is inconsistent with the modifier used on the claim.

Question 59: Which federal law governs how healthcare providers may communicate with patients about outstanding balances and prohibits abusive collection practices?

Fair Debt Collection Practices Act (FDCPA) (Correct answer)
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Emergency Medical Treatment and Labor Act (EMTALA)
Health Insurance Portability and Accountability Act (HIPAA)

Correct answer: Fair Debt Collection Practices Act (FDCPA)

The FDCPA sets rules for fair, non-harassing debt collection practices, which apply when providers or their agents contact patients about overdue balances.

Question 60: What does the acronym EOB stand for in healthcare billing?

Estimate of Balance
Evidence of Billing
Explanation of Benefits (Correct answer)
End of Billing

Correct answer: Explanation of Benefits

An Explanation of Benefits (EOB) is a statement sent to the patient or insured summarizing how a claim was processed by their insurance plan.

Question 61: What does it mean to 'balance bill' a patient?

To collect the deductible before services are rendered
To bill the patient only their copay amount
To charge the patient the difference between the provider's billed charge and the payer's allowed amount when the provider is out-of-network (Correct answer)
To send the patient a final statement after all payers have paid

Correct answer: To charge the patient the difference between the provider's billed charge and the payer's allowed amount when the provider is out-of-network

Balance billing occurs when an out-of-network provider charges the patient the difference between their billed charge and the payer's allowed amount, a practice restricted or banned in many states and federal programs.

Question 62: Which federal law governs the collection practices of third-party debt collectors pursuing patient balances on behalf of healthcare providers?

Health Insurance Portability and Accountability Act (HIPAA)
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Emergency Medical Treatment and Labor Act (EMTALA)
Fair Debt Collection Practices Act (FDCPA) (Correct answer)

Correct answer: Fair Debt Collection Practices Act (FDCPA)

The FDCPA regulates third-party collectors' conduct, including prohibitions on harassment, false statements, and unfair practices when collecting consumer debts.

Question 63: What is the purpose of a 'Level of Care' determination during the authorization process for behavioral health services?

To verify the therapist's license type with the state board
To establish that the intensity of treatment (e.g., inpatient vs. outpatient) is appropriate for the patient's clinical needs (Correct answer)
To set the patient's copay amount for mental health visits
To determine whether the patient qualifies for Medicaid

Correct answer: To establish that the intensity of treatment (e.g., inpatient vs. outpatient) is appropriate for the patient's clinical needs

A Level of Care determination ensures the proposed setting and intensity of behavioral health treatment are clinically justified and medically necessary per payer criteria.

Question 64: A patient is treated for cellulitis of the right lower leg. The ICD-10-CM code should specify:

The specific site and laterality of the cellulitis (Correct answer)
The patient's immune status
The causative organism only
Only that cellulitis is present, without site specificity

Correct answer: The specific site and laterality of the cellulitis

ICD-10-CM requires coding to the highest level of specificity, including the anatomical site and laterality when documented.

Question 65: When a financial counselor identifies that a patient has both Medicare and Medicaid coverage, the patient is called a 'dual eligible.' Which payer is billed FIRST?

Either payer, depending on the provider's preference
Medicaid, because it is the federal program
The patient is billed directly for all services
Medicare, as the primary payer, with Medicaid as the payer of last resort (Correct answer)

Correct answer: Medicare, as the primary payer, with Medicaid as the payer of last resort

For dual eligible patients, Medicare is always billed first as the primary payer, and Medicaid covers remaining cost-sharing as the payer of last resort.

Question 66: Which federal law requires hospitals to provide emergency medical screening and stabilization regardless of a patient's ability to pay?

The Affordable Care Act
The No Surprises Act
EMTALA the Emergency Medical Treatment and Labor Act (Correct answer)
HIPAA

Correct answer: EMTALA the Emergency Medical Treatment and Labor Act

EMTALA prohibits hospitals from refusing emergency care or transferring unstable patients based on their financial status.

Question 67: Under the Emergency Medical Treatment and Labor Act (EMTALA), a hospital with an emergency department must:

Transfer patients immediately if they cannot pay
Treat only patients with insurance or documented ability to pay
Only stabilize patients who are US citizens or legal residents
Provide a medical screening exam to all individuals who come to the ED regardless of ability to pay (Correct answer)

Correct answer: Provide a medical screening exam to all individuals who come to the ED regardless of ability to pay

EMTALA requires hospitals with EDs to provide a medical screening examination to anyone who presents, regardless of their ability to pay, citizenship, or insurance status.

Question 68: A patient's coinsurance is 20% after a $1,000 in-network deductible, which has been fully met. The allowed amount for today's procedure is $800. What is the patient's POS responsibility?

$800
$160 (Correct answer)
$200
$640

Correct answer: $160

Since the deductible is fully met, only the coinsurance applies: 20% of $800 = $160.

Question 69: A patient balance of $450 has been unpaid for 90 days. What is the most appropriate next step in the collections process?

Send a second collection notice and offer a payment plan (Correct answer)
Transfer the account to an external collection agency without notice
Adjust the balance off as a contractual write-off
Write off the balance immediately

Correct answer: Send a second collection notice and offer a payment plan

Standard collections protocol calls for escalating communication and offering payment arrangements before more aggressive action.

Question 70: A prior authorization for a surgical procedure was approved, but the surgery date was pushed back two weeks beyond the authorization's expiration date. What should the revenue cycle representative do?

Request an extension or a new authorization from the payer before the new surgery date (Correct answer)
Document the expired authorization and bill anyway
Have the physician sign a waiver to replace the authorization
Use the existing authorization since it was approved for the same procedure

Correct answer: Request an extension or a new authorization from the payer before the new surgery date

Expired authorizations are not valid; the representative must contact the payer to extend or reissue the authorization before the service is rendered.

Question 71: Which of the following best describes a 'soft denial' in revenue cycle management?

A denial related exclusively to coordination of benefits disputes
A denial that is permanent and cannot be appealed
A denial that can be resolved by submitting additional information or correcting the claim (Correct answer)
A denial issued by a secondary payer after primary adjudication

Correct answer: A denial that can be resolved by submitting additional information or correcting the claim

A soft denial is a temporary denial that can be overturned by providing missing information, correcting errors, or submitting supporting documentation.

Question 72: What is the role of a financial counselor in the patient access department?

To verify provider credentials and network participation
To help patients understand their insurance benefits, financial responsibilities, and available payment options including financial assistance (Correct answer)
To process insurance claims on behalf of patients
To conduct medical necessity reviews for planned admissions

Correct answer: To help patients understand their insurance benefits, financial responsibilities, and available payment options including financial assistance

Financial counselors help patients navigate the financial aspects of their care improving both the patient experience and the organization's collection performance.

Question 73: What is the consequence of billing a service that required prior authorization but for which authorization was not obtained?

The claim will typically be denied and the provider may be responsible for writing off the balance (Correct answer)
The claim will be paid after the deductible is met
The patient automatically owes the full billed charge
The claim will be paid at the standard rate

Correct answer: The claim will typically be denied and the provider may be responsible for writing off the balance

Most payers require prior authorization for specific services and failure to obtain it results in a claim denial that the provider generally cannot bill to the patient.

Question 74: What is a write-off in the context of denial resolution and when is it appropriate?

A write-off increases revenue by removing liabilities
A write-off reduces the account balance and is appropriate when an appeal has been exhausted and no further recovery is possible (Correct answer)
A write-off is always appropriate for denied claims
A write-off is the same as a contractual adjustment

Correct answer: A write-off reduces the account balance and is appropriate when an appeal has been exhausted and no further recovery is possible

Write-offs are appropriate after all appeal options have been exhausted and the denial is final with no possibility of recovery.

Question 75: A provider bills $500 for a service. The contracted rate is $300. The patient has a $50 copay. What is the contractual adjustment amount posted to the account?

$150
$200 (Correct answer)
$300
$250

Correct answer: $200

The contractual adjustment equals the billed charge minus the allowed amount: $500 − $300 = $200, which must be written off per the provider's contract.

Question 76: What does CDM stand for in revenue cycle management?

Charge Description Master (Correct answer)
Clinical Documentation Manual
Claims Data Management
Coded Diagnosis Module

Correct answer: Charge Description Master

The Charge Description Master is the comprehensive list of services, supplies, and procedures with their associated charges and codes.

CRCR Certification Exam

The HFMA Certified Revenue Cycle Representative exam validates knowledge of healthcare revenue cycle processes from patient access through final account resolution.

Questions

90 min

Time Limit

70%

To Pass

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