2024 HFMA CRCR Part 1 Latest Questions With Complete Grade A Answers
- Describe the paper and electronic claims flow process.
Answer:
- Electronic Claim Submission= EDI claims forwarded to either directly or via EDI
- Claims Verification= Clearinghouse specifications and insurance company re-
- Rejected Claims = Claims not meeting requirements returned via clearinghouse
- Accepted claims= sent to insurance company for provider ID verification.
- Providers are responsible for verification of EDI claims receipts.
- Accepted /rejected claims must be reviewed and validated against transmittal
clearing house/ vendor.
quirements used to validate transmitted claims.
error report.
records daily.
- Describe the purpose of the 835 and 837 EDI transactions.
Answer: EDI transactions include the 837 and 835 transactions.
The 837 EDI transaction is used to submit healthcare claim billing information, encounter information, or both. It can be sent from providers of healthcare services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit healthcare claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of healthcare services within a specific healthcare/insurance industry segment.The 835 EDI transaction can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a healthcare provider either directly or via a financial institution.
- Who are the typical revenue cycle team members?
Answer: Typical revenue cycle team members include the following: 1 / 3
1) Access management 2) Case management 3) Managed care contracting coordinator 4) Patient care representatives 5) CDM manager 6) Revenue integrity leader 7) Ancillary services 8) ED 9) Health information management 10) Patient financial services 11) Decision support 12) Finance and accounting (CFO) 13) Compliance 14) Information technology
- What are the 9 thing included in the team charter?
- Ensuring revenue is captured in a timely fashion
- Collecting entitled reimbursement
- Reengineering workflow processes
- Analyzing hurdles, snags
- Monitoring improvements
- Establishing metrics
- Creating policies and procedures
- Educating others
- Prioritizing projects that will yield maximum benefit for the patient and the
Answer: The team charter includes the following:
organization
- When may claims be denied? (relates to timing of denial)
Answer: Claims may be denied: 1) Prior to payment for a variety of reasons.2) Retrospectively, that is, after they have been paid by a payer, based on an audit of claims processing methods and/or review of a copy of the patient record.3) By the payer or an agent other than the original payer.
- List 8 reasons that claims may be denied prior to payment?
Answer: Claims may be denied prior to payment for a variety of reasons, such as: 2 / 3
1) Whether services provided or proposed are reasonable and medically necessary.2) Whether services furnished or proposed to be furnished on an inpatient basis could be effectively furnished on an outpatient basis.3) The medical necessity, reasonableness, and appropriateness of inpatient care for which additional payment is sought under the outlier provision of PPS.4) Whether the hospital has misrepresented admission or discharge information or taken an action that results in unnecessary admission, or other inappropriate practices.5) The validity of the diagnostic and procedural information given by the provider to the payer for payment.6) The completeness and adequacy of the hospital care provided.7) Whether the quality of service meets professionally recognized standards of care.8) Duplicate bills, usually caused by rebills or late charges, without the proper bill type code.
- Claims denied by payer or agent?
Answer: Claims may be denied by payer or by agent: 1) For non-governmental payers, the payer typically performs the review and issues the denial; however, some third party payers engage external firms to review a sample of claims as well as assess whether credit balances have been properly refunded to the patient or the payer.2) For governmental payers, there are a number of contractors that have been engaged by the federal and state governments to review claims both prospectively (prior to payment) and retrospectively (after payment). These reviews may be con- ducted on claims that are 10 years old.
- What are retrospectively denied claims?
Answer: Restrospectively Denied
Claims-----Claims may be denied retrospectively, that is, after they have been paid by a payer, based on an audit of claims processing methods and/or review of a copy of the patient record for any of, but not limited to, the aforementioned reasons.
- Medicare Administrative Contractors (MACs)
Answer: Medicare Administrative Con- tractors (MACs)
- MACs process provider claims for Medicare. During the processing stage, the
- / 3
MAC may deny a claim for any of the reasons noted earlier or if there is an unusual trend noted. The MAC's goal is to avoid paying a claim improperly at the onset rather than review and take back a payment retrospectively.