Revenue Cycle Fundamentals Flashcards

Which step in the revenue cycle occurs BEFORE a patient receives services?

Answer: Pre-authorization

Pre-authorization (prior authorization) is obtained from the payer before services are rendered to confirm coverage.

What does the term 'clean claim' mean in healthcare billing?

Answer: A claim that contains all required information and passes edits without errors

A clean claim is one that contains all required data elements and passes all payer edits, allowing it to be processed without delay.

Which federal program provides health coverage primarily to individuals with disabilities and end-stage renal disease?

Answer: Medicare

Medicare covers individuals 65 and older as well as those under 65 with qualifying disabilities or end-stage renal disease.

A patient's insurance card shows a $250 deductible, $30 copay, and 80/20 coinsurance. After meeting the deductible, who pays the 20%?

Answer: The patient

Coinsurance is the percentage of costs the patient is responsible for after the deductible has been met.

What is the purpose of a remittance advice (RA)?

Answer: To explain how a claim was processed and what the payer paid

A remittance advice explains the payer's adjudication of a claim, including payments, adjustments, and denial reasons.

Which of the following best describes 'coordination of benefits' (COB)?

Answer: A method to determine which insurer pays first when a patient has multiple coverages

COB is the process that determines the order in which multiple insurers pay claims to prevent duplicate payment.

Which 837 transaction set is used to submit professional (physician) claims electronically?

Answer: 837P

The 837P transaction is the HIPAA-standard electronic format for submitting professional/physician claims.