AAHAM CRCE 2023 EXAM STUDY GUIDE WITH COMPLETE SOLUTION

1-day payment window rule - Answer a Medicare requirement similar to the day payment window rule that applies to inpatient poychiatric hosp tals, inpatient rehabilitation facilities, long term care facilities, and chil dren's and cancer hospital. 3-day payment window rule - Answer a Medicare requirement that all diagnostic and clinically related non-diagnostic outpatient services provided with in three days of an inpatient admission must combined the inpa- tient claim when they are provided by an entity wholly owned or oper ated by the inpatient hospital (or by another entity under arrangements with the admitting hospital). 8371 - Answer the dataset that is utilized to electronically submit hospital claims to the payer. 837P - Answer the HIPAA standard transaction that replaces the CMS-1500 and is required of almost all physicians. 838 report - Answer a mandatory quarterly credit balance report used to monitor identification and recovery of credit balances owed to Medicare. Advance Beneficiary Notice ABN - Answer Document that acknowledges patient responsibility for payment if Medicare denies the claim. Agents - Answer individuals to help consumers and small businesses complete the application process and enroll in health coverage through the Marketplace Abuse - Answer incidents or practices of providers Physicians or suppliers of services that although not usually considered fraudulent are inconsistent with accepted sound medical business or fiscal practices directly or indirectly resulting in unnecessary costs to the insurer and improper reimbursement for services that fail to meet professionally recognized standards of care or that are medically unnecessary accrual method - Answer a method of accounting that generally recognizes income in the period earned and recognizes deductions in the period that liabilities are incurred. ACF - Answer Administration for Children and Families one of HHS operating divisions ACL - Answer Administration for Community Living; one of the HHS Operating Divisions. Americans with Disabilities Act, ADA - Answer Comprehensive legislation that is designed to protect individuals with disabilities against discrimination. Advanced alternative payment models, APMs - Answer one of two ways conditions can choose to participate in the quality payment program, clinicians may earn a Medicare incentive payment for sufficiently participating in an innovative payment model administrative law judge, ALJ - Answer the third level of both the Medicare and RAC appeals process Advance beneficiary notice - Answer Document that acknowledges patient responsibility for payment if Medicare denies the claim. agents - Answer individuals who help consumers and small businesses complete the application process and enroll in health care coverage through the marketplace. They are able to make recommendations about coverage and may only sell plans from specific health insurance companies AHA - Answer American Hospital Association AHRQ - Answer Agency for Healthcare Research and Quality; one of the HHS Operating Divisions ANSI - Answer American National Standards Institute Anti-Kickback Statute - Answer Prohibits offering, paying, soliciting or receiving anything of value to induce or reward referrals or generate federal healthcare program business. ambulatory payment classification, APC - Answer a payment methodology used for Medicare's OPPS which places services into groups based on similar clinical characteristics and similar cost. Each a PC has a weighted value that bundles payment for Associated services AR Days - Answer a measure of how long, on average, it takes to collect revenue from the date of discharge. Gross AR days have not had any allowances deducted, while net AR days have had some or many deductions Asset control - Answer procedures to protect assets from theft assignment of benefits - Answer patient's written authorization giving the insurance company the right to pay the physician directly for billed charges ATSDR - Answer Agency for Toxic Substances and Disease Registry; one of the HHS Operating Divisions. Automated - Answer a type of RAC review where the RAC merely identifies a potential issue and uses its database to find improper payments. The provider is then given notification of denied claims average daily census, ADC - Answer the total number of patient days in a given time Divided by the number of days in that period average length of stay, ALOS - Answer a metric calculated by dividing the total number of patient Days by the number of discharges balanced budget act, BBA - Answer one of numerous laws that have determined when Medicare is primary beneficiary - Answer a person who has healthcare insurance for Medicare Birthday rule - Answer determines coordination of benefits for a child covered by both parents. It dictates that the parent with the first birthday in the calendar year will provide the primary coverage. If both parents happen to have the same birthday, the plan that has covered a parent longer pays first Call centers - Answer an option for consumers to ask questions about health coverage options and obtain assistance with the Marketplace application process. Capitation - Answer a method of payment in which a provider is paid a set dollar amount for each patient for a specific time period, and that payment covers all care the group of patients receive for that period, no matter the actual charges case management - Answer also known as utilization review or UR, an area that works with patient access in a collaborative approach that includes assessing providing coordinating and monitoring Coordinated Care plan, CCP - Answer the top of health care plan used by Medicare Advantage plans. It includes hmos ppos PFFS plans SMPs and MSAs certified application counselor - Answer individuals who fulfill some of the same roles as Navigators and non Navigators. They are not responsible for outreach and education but they do provide free information to customers about insurance programs. They assist them in applying for coverage, and they help to facilitate the enrollment in health coverage Chapter 7 Bankruptcy - Answer the type of bankruptcy where the debtor does not have any means to repay debts, assets, if any, are divided among the creditors according to precedent. Legal fees, then secured debts, then unsecured debt such as medical bills Chapter 11 Bankruptcy - Answer the type of bankruptcy frequently referred to as a reorganization. It gives a distressed business a reprieve from creditor claim while it continues to function and works out a repayment plan Chapter 12 Bankruptcy - Answer A form of bankruptcy that lets family farmers and fishing businesses create a plan for debt repayment that allows them to keep their operations running Chapter 13 Bankruptcy - Answer a reorganization form of bankruptcy for individuals that allows the debtors to keep their property and use their income to pay a portion of their debts over three to five years