CRCR PRACTICE EXAM: BILLING, CLAIMS & COMPLIANCE EXAM 2026 EDTION
|quESTIONS AND ANSwERS wITh RATIONALES/GRADED A+/2026 uPDATE/100%
CORRECT /INSTANT DOwNLOAD
SECTION 1: BILLING FUNDAMENTALS (QUESTIONS 1-15)
Question 1
What is the difference between a UB-04 and a CMS-1500 claim form?
A) UB-04 is for institutional (facility) claims; CMS-1500 is for professional (physician) claims
B) UB-04 is for professional claims; CMS-1500 is for institutional claims
C) Both forms are for the same purpose
D) Neither form is used anymore
Answer: A) UB-04 is for institutional (facility) claims; CMS-1500 is for professional (physician) claims
Rationale: The UB-04 (also known as CMS-1450) is used for institutional claims from hospitals, skilled
nursing facilities, and home health agencies. The CMS-1500 is used for professional claims from
physicians, nurse practitioners, and other individual providers. Some providers must submit both
types of claims for the same patient encounter.
Question 2
What is the purpose of revenue codes on an institutional claim (UB-04)?
A) To identify the specific procedure performed
B) To identify the department or cost center where services were provided
C) To identify the patient's diagnosis
D) To identify the provider's name
Answer: B) To identify the department or cost center where services were provided
,Rationale: Revenue codes are three-digit codes on the UB-04 claim form that identify the specific
department or cost center where services were provided. Examples include revenue code 0450 for
emergency department, 0360 for operating room, and 0250 for pharmacy. Revenue codes are used for
institutional billing; CPT codes are used on professional claims.
Question 3
What is an Explanation of Benefits (EOB)?
A) A document explaining the patient's medical condition
B) A statement from the insurance company explaining how a claim was processed, including amounts
paid, denied, adjusted, and patient responsibility
C) A billing statement from the provider
D) A prescription form
Answer: B) A statement from the insurance company explaining how a claim was processed
Rationale: An Explanation of Benefits (EOB) is a document from the health insurance company that
explains how a claim was processed. It shows the billed amount, allowed amount, adjustments,
amount paid to the provider, and patient responsibility. The EOB is not a bill but an explanation of
claim processing.
Question 4
What is the purpose of the National Provider Identifier (NPI)?
A) To identify patients
B) To uniquely identify healthcare providers for billing and electronic transactions
C) To identify insurance plans
D) To identify medications
Answer: B) To uniquely identify healthcare providers for billing and electronic transactions
,Rationale: The National Provider Identifier (NPI) is a unique 10-digit identifier for healthcare
providers in the United States. All covered entities under HIPAA must use NPIs in standard electronic
transactions, including claims. The NPI replaces legacy provider identifiers and allows for standardized
provider identification across payers.
Question 5
What is a clean claim?
A) A claim that has no patient information
B) A claim that can be processed without external investigation or additional information
C) A claim that is always paid in full
D) A claim that is submitted on paper
Answer: B) A claim that can be processed without external investigation or additional information
Rationale: A clean claim is a claim that contains all required information, is properly coded, and can
be processed without external investigation or additional information. The Affordable Care Act
requires that clean claims be paid within 30 days for Medicare and typically 30-45 days for commercial
payers. Clean claim rates are a key revenue cycle metric.
Question 6
What is the timely filing limit for most Medicare claims?
A) 30 days from date of service
B) 90 days from date of service
C) 12 months (365 days) from date of service
D) No time limit
Answer: C) 12 months (365 days) from date of service
, Rationale: Medicare generally requires claims to be submitted within 12 months (365 days) from the
date of service. Timely filing limits vary by payer; commercial payers often have shorter limits (90-180
days). Failure to meet timely filing deadlines results in automatic claim denial. Some Medicare
Advantage plans have shorter filing limits.
Question 7
What is a claim scrubber?
A) A cleaning product for paper claims
B) Software that automatically checks claims for errors, missing information, and coding issues before
submission
C) A person who cleans medical records
D) A type of insurance plan
Answer: B) Software that automatically checks claims for errors, missing information, and coding
issues before submission
Rationale: A claim scrubber (also called claims editing software) is a technology tool that
automatically checks claims for errors, missing information, coding inconsistencies, and compliance
issues before submission to payers. Using a claim scrubber reduces denials, accelerates payment, and
improves clean claim rates.
Question 8
What is the electronic transaction standard for healthcare claims under HIPAA?
A) X12 5010 (ASC X12 005010X222A1)
B) PDF format
C) Paper CMS-1500
D) Email
Answer: A) X12 5010 (ASC X12 005010X222A1)
|quESTIONS AND ANSwERS wITh RATIONALES/GRADED A+/2026 uPDATE/100%
CORRECT /INSTANT DOwNLOAD
SECTION 1: BILLING FUNDAMENTALS (QUESTIONS 1-15)
Question 1
What is the difference between a UB-04 and a CMS-1500 claim form?
A) UB-04 is for institutional (facility) claims; CMS-1500 is for professional (physician) claims
B) UB-04 is for professional claims; CMS-1500 is for institutional claims
C) Both forms are for the same purpose
D) Neither form is used anymore
Answer: A) UB-04 is for institutional (facility) claims; CMS-1500 is for professional (physician) claims
Rationale: The UB-04 (also known as CMS-1450) is used for institutional claims from hospitals, skilled
nursing facilities, and home health agencies. The CMS-1500 is used for professional claims from
physicians, nurse practitioners, and other individual providers. Some providers must submit both
types of claims for the same patient encounter.
Question 2
What is the purpose of revenue codes on an institutional claim (UB-04)?
A) To identify the specific procedure performed
B) To identify the department or cost center where services were provided
C) To identify the patient's diagnosis
D) To identify the provider's name
Answer: B) To identify the department or cost center where services were provided
,Rationale: Revenue codes are three-digit codes on the UB-04 claim form that identify the specific
department or cost center where services were provided. Examples include revenue code 0450 for
emergency department, 0360 for operating room, and 0250 for pharmacy. Revenue codes are used for
institutional billing; CPT codes are used on professional claims.
Question 3
What is an Explanation of Benefits (EOB)?
A) A document explaining the patient's medical condition
B) A statement from the insurance company explaining how a claim was processed, including amounts
paid, denied, adjusted, and patient responsibility
C) A billing statement from the provider
D) A prescription form
Answer: B) A statement from the insurance company explaining how a claim was processed
Rationale: An Explanation of Benefits (EOB) is a document from the health insurance company that
explains how a claim was processed. It shows the billed amount, allowed amount, adjustments,
amount paid to the provider, and patient responsibility. The EOB is not a bill but an explanation of
claim processing.
Question 4
What is the purpose of the National Provider Identifier (NPI)?
A) To identify patients
B) To uniquely identify healthcare providers for billing and electronic transactions
C) To identify insurance plans
D) To identify medications
Answer: B) To uniquely identify healthcare providers for billing and electronic transactions
,Rationale: The National Provider Identifier (NPI) is a unique 10-digit identifier for healthcare
providers in the United States. All covered entities under HIPAA must use NPIs in standard electronic
transactions, including claims. The NPI replaces legacy provider identifiers and allows for standardized
provider identification across payers.
Question 5
What is a clean claim?
A) A claim that has no patient information
B) A claim that can be processed without external investigation or additional information
C) A claim that is always paid in full
D) A claim that is submitted on paper
Answer: B) A claim that can be processed without external investigation or additional information
Rationale: A clean claim is a claim that contains all required information, is properly coded, and can
be processed without external investigation or additional information. The Affordable Care Act
requires that clean claims be paid within 30 days for Medicare and typically 30-45 days for commercial
payers. Clean claim rates are a key revenue cycle metric.
Question 6
What is the timely filing limit for most Medicare claims?
A) 30 days from date of service
B) 90 days from date of service
C) 12 months (365 days) from date of service
D) No time limit
Answer: C) 12 months (365 days) from date of service
, Rationale: Medicare generally requires claims to be submitted within 12 months (365 days) from the
date of service. Timely filing limits vary by payer; commercial payers often have shorter limits (90-180
days). Failure to meet timely filing deadlines results in automatic claim denial. Some Medicare
Advantage plans have shorter filing limits.
Question 7
What is a claim scrubber?
A) A cleaning product for paper claims
B) Software that automatically checks claims for errors, missing information, and coding issues before
submission
C) A person who cleans medical records
D) A type of insurance plan
Answer: B) Software that automatically checks claims for errors, missing information, and coding
issues before submission
Rationale: A claim scrubber (also called claims editing software) is a technology tool that
automatically checks claims for errors, missing information, coding inconsistencies, and compliance
issues before submission to payers. Using a claim scrubber reduces denials, accelerates payment, and
improves clean claim rates.
Question 8
What is the electronic transaction standard for healthcare claims under HIPAA?
A) X12 5010 (ASC X12 005010X222A1)
B) PDF format
C) Paper CMS-1500
D) Email
Answer: A) X12 5010 (ASC X12 005010X222A1)
