CRCR CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing 4 — Questions and Answers
Question 1: What is the primary purpose of a remittance advice (RA) in the revenue cycle?
- To communicate the payer's adjudication decisions including payments, adjustments, and denials (Correct answer)
- To authorize future services for a patient
- To verify a patient's insurance eligibility
- To notify providers of upcoming fee schedule changes
Correct answer: To communicate the payer's adjudication decisions including payments, adjustments, and denials
The remittance advice details how each claim line was processed, including allowed amounts, contractual adjustments, patient responsibility, and denial reasons.
Question 2: Which of the following is an example of an ANSI reason code that indicates patient responsibility?
- PR-1: Deductible amount (Correct answer)
- CO-45: Charges exceed fee schedule
- OA-23: Offset adjustment
- CO-97: Claim bundled
Correct answer: PR-1: Deductible amount
PR (Patient Responsibility) codes such as PR-1 identify amounts that the payer has determined are owed by the patient rather than the plan.
Question 3: A provider submits a claim within the timely filing deadline, but the payer denies it stating the deadline was missed. What documentation should the provider gather to appeal?
- Proof of timely submission such as a clearinghouse acceptance report or certified mail receipt (Correct answer)
- A new authorization for the services
- An updated certificate of coverage from the payer
- A corrected claim with a different date of service
Correct answer: Proof of timely submission such as a clearinghouse acceptance report or certified mail receipt
To overturn a timely filing denial, the provider must submit documented evidence that the claim was received or transmitted within the required timeframe.
Question 4: Under HIPAA, what is the maximum number of days a payer generally has to acknowledge receipt of an electronic claim?
- 2 business days (Correct answer)
- 30 calendar days
- 7 calendar days
- 14 business days
Correct answer: 2 business days
HIPAA electronic transaction standards require trading partners to acknowledge receipt of an 837 transaction within 2 business days via a 999 or TA1 acknowledgment.
Question 5: 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?
- $200 (Correct answer)
- $250
- $150
- $300
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 6: Which revenue code on a UB-04 is used to bill for routine daily room and board charges in a semi-private room?
- 0120 (Correct answer)
- 0250
- 0360
- 0450
Correct answer: 0120
Revenue code 0120 represents accommodation charges for a semi-private room (two or more beds) for inpatient daily room and board.
Question 7: What does a 'split billing' scenario require when a service spans more than one calendar month in an inpatient stay?
- The provider must submit separate claims for each calendar month of the stay (Correct answer)
- The entire stay is billed on one claim using the discharge date
- The payer automatically splits the claim at month-end
- Only the first month's charges are billable under most contracts
Correct answer: The provider must submit separate claims for each calendar month of the stay
When an inpatient stay crosses a calendar month boundary, most payers require separate UB-04 claims for each month to properly apply benefits and process interim bills.
CRCR CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing 4
What is the primary purpose of a remittance advice (RA) in the revenue cycle?