CRCR EXAMS C COMPLETE COURSE REVIEW
GUIDE
◉ What is NOT a typical charge master problem that can result in a
denial?
Answer: Does not include required modifiers
◉ Access
Answer: An individual's ability to obtain medical services on a
timely and financially acceptable level
◉ Administrative Services Only (ASO)
Answer: Usually contracted administrative services to a self-insured
health plan
◉ Case management
Answer: The process whereby all health-related components of a
case are managed by a designated health professional. Intended to
ensure continuity of healthcare accessibility and services
◉ Claim
Answer: A demand by an insured person for the benefits provided
by the group contract
,◉ Coordination of benefits (COB)
Answer: a typical insurance provision that determines the
responsibility for primary payment when the patient is covered by
more than one employer-sponsored health benefit program
◉ Discounted fee-for-service
Answer: A reimbursement methodology whereby a provider agrees
to provide service on a fee for service basis, but the fees are
discounted by certain packages
◉ Eligibility
Answer: Patient status regarding coverage for healthcare insurance
benefits
◉ First dollar coverage
Answer: A healthcare insurance policy that has no deductible and
covers the first dollar of an insured's expenses
◉ Gatekeeping
Answer: A concept wherein the primary care physician provides all
primary patient care and coordinates all diagnostic testing and
specialty referrals required for a patient's medical care
,◉ Health plan
Answer: an insurance company that provides for the delivery or
payment of healthcare services
◉ Indemnity insurance
Answer: negotiated healthcare coverage within a framework of fee
schedules, limitations, and exclusions that is offered by insurance
companies or benevolent associations
◉ Medically necessary
Answer: Healthcare services that are required to preserve or
maintain a person's health status in accordance with medical
practice standards
◉ Out-of-area benefits
Answer: healthcare plan coverage allowed to covered persons for
emergency situations outside of the prescribed geographic area of
the HMO
◉ Out-of-pocket payments
Answer: Cash payments made by the insured for services not
covered by the health insurance plan
◉ Pre-admission review
, Answer: 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
Answer: A restriction on payments for charges directly resulting
from a pre-existing health conditions
◉ Same-day admission
Answer: 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
Answer: Large employers who assume direct responsibility or risk
for paying employees' healthcare without purchasing health
insurance
◉ Subrogation
Answer: Seeking, by legal or administrative means, reimbursement
from another party that is primarily responsible for a patient's
medical expenses
GUIDE
◉ What is NOT a typical charge master problem that can result in a
denial?
Answer: Does not include required modifiers
◉ Access
Answer: An individual's ability to obtain medical services on a
timely and financially acceptable level
◉ Administrative Services Only (ASO)
Answer: Usually contracted administrative services to a self-insured
health plan
◉ Case management
Answer: The process whereby all health-related components of a
case are managed by a designated health professional. Intended to
ensure continuity of healthcare accessibility and services
◉ Claim
Answer: A demand by an insured person for the benefits provided
by the group contract
,◉ Coordination of benefits (COB)
Answer: a typical insurance provision that determines the
responsibility for primary payment when the patient is covered by
more than one employer-sponsored health benefit program
◉ Discounted fee-for-service
Answer: A reimbursement methodology whereby a provider agrees
to provide service on a fee for service basis, but the fees are
discounted by certain packages
◉ Eligibility
Answer: Patient status regarding coverage for healthcare insurance
benefits
◉ First dollar coverage
Answer: A healthcare insurance policy that has no deductible and
covers the first dollar of an insured's expenses
◉ Gatekeeping
Answer: A concept wherein the primary care physician provides all
primary patient care and coordinates all diagnostic testing and
specialty referrals required for a patient's medical care
,◉ Health plan
Answer: an insurance company that provides for the delivery or
payment of healthcare services
◉ Indemnity insurance
Answer: negotiated healthcare coverage within a framework of fee
schedules, limitations, and exclusions that is offered by insurance
companies or benevolent associations
◉ Medically necessary
Answer: Healthcare services that are required to preserve or
maintain a person's health status in accordance with medical
practice standards
◉ Out-of-area benefits
Answer: healthcare plan coverage allowed to covered persons for
emergency situations outside of the prescribed geographic area of
the HMO
◉ Out-of-pocket payments
Answer: Cash payments made by the insured for services not
covered by the health insurance plan
◉ Pre-admission review
, Answer: 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
Answer: A restriction on payments for charges directly resulting
from a pre-existing health conditions
◉ Same-day admission
Answer: 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
Answer: Large employers who assume direct responsibility or risk
for paying employees' healthcare without purchasing health
insurance
◉ Subrogation
Answer: Seeking, by legal or administrative means, reimbursement
from another party that is primarily responsible for a patient's
medical expenses
