CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing Questions and Answers

Question 1

A hospital billing department submits a batch of claims to a third-party entity that reviews the claims for errors, standardizes the data into the HIPAA-compliant format, and then routes them to the appropriate insurance payers. What is this third-party entity called?

Accepted Answer

Healthcare Clearinghouse

Answer

A healthcare clearinghouse acts as an intermediary between healthcare providers and payers. Its primary functions are to receive claims, check them for errors (a process called 'scrubbing'), convert them into a standard electronic format (like ANSI X12 837), and then transmit the clean claims to the correct payers.

Question 2

A patient receives a document from their insurance company that details the services billed by the provider, the amount covered by insurance, and the remaining balance the patient is responsible for. This document is not a bill. Which of the following is it?

Accepted Answer

Explanation of Benefits (EOB)

Answer

An Explanation of Benefits (EOB) is a statement sent from the insurance company to the patient. It explains what medical treatments and/or services were paid for on their behalf. It is not a bill. An Electronic Remittance Advice (ERA) contains similar payment information but is sent electronically from the payer to the provider.

Question 3

A clinic uses software to automatically review outpatient claims for missing diagnosis codes, incorrect patient demographic information, and potential unbundling issues before they are sent to the payer. What is this automated review process known as?

Accepted Answer

Claim Scrubbing

Answer

Claim scrubbing is the process of reviewing a claim to check for errors and ensure it meets payer-specific requirements and formatting guidelines before submission. This process helps to increase the clean claim rate, reduce denials, and accelerate reimbursement.

Question 4

A claim is denied with a Claim Adjustment Reason Code (CARC) of CO-29. What is the most likely reason for this denial?

Accepted Answer

The claim was submitted after the payer's filing deadline.

Answer

The denial code CO-29 specifically indicates that the time limit for filing the claim has expired. Payers have specific timely filing limits, and claims submitted after this window will be denied.

Question 5

A patient is seen by their primary care physician for a follow-up visit. Which standard claim form would be used to bill for the physician's professional services?

Accepted Answer

CMS-1500 (HCFA-1500)

Answer

The CMS-1500 form is the standard claim form used by individual healthcare providers, such as physicians and other professionals, to bill for their services. The UB-04 form is used by institutional facilities, like hospitals and skilled nursing facilities, to bill for their services (facility fees, room and board, etc.).

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Claims Processing and Billing Questions and Answers