REVENUE CYCLE MANAGEMENT EXAM
QUESTIONS AND ANSWERS (GRADED
A+)
Revenue Cycle Management/Accounts Receivable Management - ANSWER-The
process by which health care facilities and providers ensure their financial viability by
increasing revenue, improving cash flow, and enhancing the patient's experience.
Claims Rejections - ANSWER-Unpaid claims that fail to meet certain data.
Claims Denials - ANSWER-Unpaid claims that contain beneficiary identification errors,
coding errors, diagnoses that do not support medical necessity of procedures/services
performed, duplicate claims, global days of surgery E/M coverage issues, national
correct coding initiative edits and outpatient code editor issues, and other patient
coverage issues.
Quarterly Provider Updates (QPUs) - ANSWER-Regulations and major policies
implemented or cancelled, new and revised manual instructions, regulations that
establish or modify the way CMS administers its programs.
Utilization Management/Utilization Review - ANSWER-Method of controlling healthcare
cost and quality of care by reviewing the appropriateness and necessity of care
provided to patients prior to the administration of care or after care has been provided.
Prospective Review - ANSWER-Prior to the administration of care.
Retrospective Review - ANSWER-After care has been provided.
Preadmission Certification (PAC)/Preadmission Review - ANSWER-Review for medical
necessity of inpatient care prior to the patient's admission.
Preauthorization/Precertification/Prior Approval/ Prior Authorization - ANSWER-Review
by health plans to grant prior approval for reimbursement of health care services.
Concurrent Review - ANSWER-Review for medical necessity of tests and procedures
ordered during an inpatient hospitalization.
Discharge Planning - ANSWER-Arranging appropriate healthcare services for the
discharged patient.
Revenue Cycle Monitoring - ANSWER-Assessing the revenue cycle to ensure financial
viability and stability using metrics.
, Metrics - ANSWER-Standards of measurement
Revenue Cycle Auditing - ANSWER-An assessment process that is conducted as a
follow-up to revenue cycle monitoring so that areas of poor performance can be
identified and corrected.
Resource Allocation - ANSWER-Distribution of financial resources among competing
groups.
Resource Allocation Monitoring - ANSWER-Uses data analytics to measure whether a
health care provider or organization achieves operational goals and objectives within
the confines of the distribution of financial resources, such as appropriately expending
budgeted amounts as well as conserving resources and protecting assets while
providing quality patient care.
Data Analytics - ANSWER-Tools and systems that are used to analyze clinical and
financial data, conduct research, and evaluate the effectiveness of disease treatments.
Data Warehouses - ANSWER-Databases that use reporting interfaces to consolidate
multiple databases, allowing reports to be generated from a single request.
Data Mining - ANSWER-Extracting and analyzing data to identify patterns, whether
predictable or unpredictable.
Encounter Form/Superbill - ANSWER-Financial record source document used by health
care providers and other personnel to record treated diagnoses and services rendered
to the patient during the current encounter.
Value-Added Network (VAN) - ANSWER-Clearinghouse that involves value-added
vendors, such as banks, in the processing of claims.
Electronic Healthcare Network Accreditation Commission (EHNAC) - ANSWER-
Determines whether a clearinghouse is accredited.
Electronic Flat File Format/Electronic Media Claim - ANSWER-A series of fixed-length
records submitted to payers as a bill for health care services.
ANSI ASC X12N - ANSWER-An electronic format standard that uses a variable length
file format to process transactions for institutional, professional, dental, and drug claims.
Electronic Data Interchange (EDI) - ANSWER-the computer-to-computer transfer of
data between providers and third-party payers in a data format agreed upon by sending
and receiving parties.
QUESTIONS AND ANSWERS (GRADED
A+)
Revenue Cycle Management/Accounts Receivable Management - ANSWER-The
process by which health care facilities and providers ensure their financial viability by
increasing revenue, improving cash flow, and enhancing the patient's experience.
Claims Rejections - ANSWER-Unpaid claims that fail to meet certain data.
Claims Denials - ANSWER-Unpaid claims that contain beneficiary identification errors,
coding errors, diagnoses that do not support medical necessity of procedures/services
performed, duplicate claims, global days of surgery E/M coverage issues, national
correct coding initiative edits and outpatient code editor issues, and other patient
coverage issues.
Quarterly Provider Updates (QPUs) - ANSWER-Regulations and major policies
implemented or cancelled, new and revised manual instructions, regulations that
establish or modify the way CMS administers its programs.
Utilization Management/Utilization Review - ANSWER-Method of controlling healthcare
cost and quality of care by reviewing the appropriateness and necessity of care
provided to patients prior to the administration of care or after care has been provided.
Prospective Review - ANSWER-Prior to the administration of care.
Retrospective Review - ANSWER-After care has been provided.
Preadmission Certification (PAC)/Preadmission Review - ANSWER-Review for medical
necessity of inpatient care prior to the patient's admission.
Preauthorization/Precertification/Prior Approval/ Prior Authorization - ANSWER-Review
by health plans to grant prior approval for reimbursement of health care services.
Concurrent Review - ANSWER-Review for medical necessity of tests and procedures
ordered during an inpatient hospitalization.
Discharge Planning - ANSWER-Arranging appropriate healthcare services for the
discharged patient.
Revenue Cycle Monitoring - ANSWER-Assessing the revenue cycle to ensure financial
viability and stability using metrics.
, Metrics - ANSWER-Standards of measurement
Revenue Cycle Auditing - ANSWER-An assessment process that is conducted as a
follow-up to revenue cycle monitoring so that areas of poor performance can be
identified and corrected.
Resource Allocation - ANSWER-Distribution of financial resources among competing
groups.
Resource Allocation Monitoring - ANSWER-Uses data analytics to measure whether a
health care provider or organization achieves operational goals and objectives within
the confines of the distribution of financial resources, such as appropriately expending
budgeted amounts as well as conserving resources and protecting assets while
providing quality patient care.
Data Analytics - ANSWER-Tools and systems that are used to analyze clinical and
financial data, conduct research, and evaluate the effectiveness of disease treatments.
Data Warehouses - ANSWER-Databases that use reporting interfaces to consolidate
multiple databases, allowing reports to be generated from a single request.
Data Mining - ANSWER-Extracting and analyzing data to identify patterns, whether
predictable or unpredictable.
Encounter Form/Superbill - ANSWER-Financial record source document used by health
care providers and other personnel to record treated diagnoses and services rendered
to the patient during the current encounter.
Value-Added Network (VAN) - ANSWER-Clearinghouse that involves value-added
vendors, such as banks, in the processing of claims.
Electronic Healthcare Network Accreditation Commission (EHNAC) - ANSWER-
Determines whether a clearinghouse is accredited.
Electronic Flat File Format/Electronic Media Claim - ANSWER-A series of fixed-length
records submitted to payers as a bill for health care services.
ANSI ASC X12N - ANSWER-An electronic format standard that uses a variable length
file format to process transactions for institutional, professional, dental, and drug claims.
Electronic Data Interchange (EDI) - ANSWER-the computer-to-computer transfer of
data between providers and third-party payers in a data format agreed upon by sending
and receiving parties.
