Revenue Cycle Fundamentals Flashcards

A payer denies a claim with reason code CO-4. What does this typically indicate?

Answer: The procedure code is inconsistent with the modifier or required modifier is missing

CO-4 is a standard CARC indicating the procedure code is inconsistent with the modifier used or a required modifier is absent.

Which type of health plan requires patients to choose a primary care physician (PCP) who manages referrals to specialists?

Answer: HMO

HMOs (Health Maintenance Organizations) require members to select a PCP who coordinates all care and provides referrals to in-network specialists.

What is the primary purpose of the National Provider Identifier (NPI)?

Answer: To uniquely identify healthcare providers in HIPAA standard transactions

The NPI is a 10-digit number assigned to healthcare providers and is required on all HIPAA-standard electronic transactions.

When a patient's insurance is billed but pays less than the contracted rate, which adjustment code category is typically used?

Answer: CO (Contractual Obligation)

CO adjustments represent contractual obligations — amounts written off per the provider's agreement with the payer.

What does 'timely filing' refer to in medical billing?

Answer: The deadline by which a claim must be submitted to the payer after the date of service

Timely filing is the payer-set deadline for claim submission; claims filed after this window are typically denied with no recourse.

Which of the following describes a 'capitation' payment model?

Answer: The provider receives a set dollar amount per enrolled member per month regardless of services rendered

Capitation pays providers a fixed per-member per-month (PMPM) amount regardless of how many or which services are actually provided.

What is the role of a clearinghouse in the revenue cycle?

Answer: To act as an intermediary that translates and transmits claims between providers and payers

A clearinghouse receives electronic claims from providers, checks them for errors, reformats them if needed, and forwards them to the appropriate payers.