CERTIFIED REVENUE CYCLE REPRESENTATIVE MAIN
EXAMINATION SET QUESTIONS AND ANSWERS SURE A+
✔✔Indemnity insurance - ✔✔negotiated healthcare coverage within a framework of fee
schedules, limitations, and exclusions that is offered by insurance companies or
benevolent associations
✔✔Medically necessary - ✔✔Healthcare services that are required to preserve or
maintain a person's health status in accordance with medical practice standards
✔✔Out-of-area benefits - ✔✔healthcare plan coverage allowed to covered persons for
emergency situations outside of the prescribed geographic area of the HMO
✔✔Out-of-pocket payments - ✔✔Cash payments made by the insured for services not
covered by the health insurance plan
✔✔Pre-admission review - ✔✔the practice of reviewing requests for inpatient admission
before the patient is admitted to ensure that the admission is medically necesary
✔✔Pre-existing condition limitation - ✔✔A restriction on payments for charges directly
resulting from a pre-existing health conditions
✔✔Same-day admission - ✔✔A cost containment practice that reduces a surgical
patient's inpatient stay by requiring that pre-procedure testing and preparation are
completed on an outpatient basis and the patient is admitted the same day as the
procedure
✔✔Self-insured - ✔✔Large employers who assume direct responsibility or risk for
paying employees' healthcare without purchasing health insurance
✔✔Subrogation - ✔✔Seeking, by legal or administrative means, reimbursement from
another party that is primarily responsible for a patient's medical expenses
✔✔Subscriber - ✔✔An employer, a union, or an association that contracts with an
insurance company for the healthcare plan it offers to eligible employees
✔✔Sub-specialist - ✔✔A healthcare professional who is recognized to have expertise in
a specialty of medicine or surgery
✔✔Third-part administrator (TPA) - ✔✔Provides services to employers or insurance
companies for utilization review, claims payment and benefit design
, ✔✔Third-party reimbursement - ✔✔A general term used for the healthcare benefit
payments - used to identify that for benefit plans there are three parties in the
transaction
✔✔Usual, customary, and reasonable (UCR) - ✔✔Health insurance plan reimbursement
methodology that limits payment to the lower billed charges, the provider's customary
charge, or the prevailing charge for the service in the community
✔✔Utilization review - ✔✔Review conducted by professional healthcare personnel of
the appropriateness of, quality of, and need for healthcare services provided to patients
✔✔Charge - ✔✔The dollar amount a provider sets for services rendered before
negotiating any discounts. The charge can be different from the amount paid
✔✔Cost - ✔✔The definition of cost varies by party incurring the expense
✔✔Price - ✔✔the total amount a provider expects to be paid by payers and patients for
healthcare services
✔✔Care purchaser - ✔✔Individual or entity that contributes to the purchase of
healthcare services
✔✔Payer - ✔✔An organization that negotiates or sets rates for provider services,
collects revenue through premium payments or tax dollars, processes provider claims
for service, and pays provider claims using collected premium or tax revenues
✔✔Provider - ✔✔An entity, organization, or individual that furnishes a healthcare
service
✔✔Out of pocket payment - ✔✔The portion of the total payment for medical services
and treatment for which the patient is responsible, including copayments, coinsurance,
and deductibles
✔✔Price transparency - ✔✔In health care, readily available information on the price of
healthcare services that, together, with other information helps define the value of those
services and enables patients and other care purchasers to identify, compare, and
choose providers that offer the desired level of value
✔✔Value - ✔✔The quality of a healthcare service in relation to the total price paid for
the service by care purchasers
✔✔What areas does the code of conduct typically focus on? - ✔✔Human resources.
Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest.
Laws/regulations
EXAMINATION SET QUESTIONS AND ANSWERS SURE A+
✔✔Indemnity insurance - ✔✔negotiated healthcare coverage within a framework of fee
schedules, limitations, and exclusions that is offered by insurance companies or
benevolent associations
✔✔Medically necessary - ✔✔Healthcare services that are required to preserve or
maintain a person's health status in accordance with medical practice standards
✔✔Out-of-area benefits - ✔✔healthcare plan coverage allowed to covered persons for
emergency situations outside of the prescribed geographic area of the HMO
✔✔Out-of-pocket payments - ✔✔Cash payments made by the insured for services not
covered by the health insurance plan
✔✔Pre-admission review - ✔✔the practice of reviewing requests for inpatient admission
before the patient is admitted to ensure that the admission is medically necesary
✔✔Pre-existing condition limitation - ✔✔A restriction on payments for charges directly
resulting from a pre-existing health conditions
✔✔Same-day admission - ✔✔A cost containment practice that reduces a surgical
patient's inpatient stay by requiring that pre-procedure testing and preparation are
completed on an outpatient basis and the patient is admitted the same day as the
procedure
✔✔Self-insured - ✔✔Large employers who assume direct responsibility or risk for
paying employees' healthcare without purchasing health insurance
✔✔Subrogation - ✔✔Seeking, by legal or administrative means, reimbursement from
another party that is primarily responsible for a patient's medical expenses
✔✔Subscriber - ✔✔An employer, a union, or an association that contracts with an
insurance company for the healthcare plan it offers to eligible employees
✔✔Sub-specialist - ✔✔A healthcare professional who is recognized to have expertise in
a specialty of medicine or surgery
✔✔Third-part administrator (TPA) - ✔✔Provides services to employers or insurance
companies for utilization review, claims payment and benefit design
, ✔✔Third-party reimbursement - ✔✔A general term used for the healthcare benefit
payments - used to identify that for benefit plans there are three parties in the
transaction
✔✔Usual, customary, and reasonable (UCR) - ✔✔Health insurance plan reimbursement
methodology that limits payment to the lower billed charges, the provider's customary
charge, or the prevailing charge for the service in the community
✔✔Utilization review - ✔✔Review conducted by professional healthcare personnel of
the appropriateness of, quality of, and need for healthcare services provided to patients
✔✔Charge - ✔✔The dollar amount a provider sets for services rendered before
negotiating any discounts. The charge can be different from the amount paid
✔✔Cost - ✔✔The definition of cost varies by party incurring the expense
✔✔Price - ✔✔the total amount a provider expects to be paid by payers and patients for
healthcare services
✔✔Care purchaser - ✔✔Individual or entity that contributes to the purchase of
healthcare services
✔✔Payer - ✔✔An organization that negotiates or sets rates for provider services,
collects revenue through premium payments or tax dollars, processes provider claims
for service, and pays provider claims using collected premium or tax revenues
✔✔Provider - ✔✔An entity, organization, or individual that furnishes a healthcare
service
✔✔Out of pocket payment - ✔✔The portion of the total payment for medical services
and treatment for which the patient is responsible, including copayments, coinsurance,
and deductibles
✔✔Price transparency - ✔✔In health care, readily available information on the price of
healthcare services that, together, with other information helps define the value of those
services and enables patients and other care purchasers to identify, compare, and
choose providers that offer the desired level of value
✔✔Value - ✔✔The quality of a healthcare service in relation to the total price paid for
the service by care purchasers
✔✔What areas does the code of conduct typically focus on? - ✔✔Human resources.
Privacy/confidentiality. Quality of care. Billing/coding. Conflicts of interest.
Laws/regulations
