CRCR Claims Processing and Billing 5

Question 1

What does 'coordination of benefits' (COB) determine in the claims billing process?

Accepted Answer

The order in which multiple insurers pay claims when a patient has more than one insurance plan

Answer

COB rules establish which insurer pays first (primary) and which pays second (secondary) when a patient has coverage under multiple plans.

Question 2

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

Accepted Answer

Administrative or demographic rejection

Answer

Incorrect demographic information such as date of birth results in an administrative or demographic rejection because the patient cannot be identified.

Question 3

Which federal law sets the standard electronic transaction formats for healthcare claims, including the HIPAA 837 transaction set?

Accepted Answer

The Health Insurance Portability and Accountability Act (HIPAA)

Answer

HIPAA established standardized electronic transaction formats, including the 837P and 837I for professional and institutional claims, respectively.

Question 4

A skilled nursing facility (SNF) bills Medicare under the Prospective Payment System (PPS). What is the payment unit for SNF PPS?

Accepted Answer

Per diem (daily rate) based on Resource Utilization Groups (RUGs)

Answer

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.

Question 5

A payer issues an Explanation of Benefits (EOB) showing a 'contractual adjustment.' What does this mean for the provider?

Accepted 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

Answer

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.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Claims Processing and Billing 5