CHAM Definitions UPDATED Exam
Questions and CORRECT Answers
Accepting Assignment, - CORRECT ANSWER - When a provider agrees to accept the
allowable charges as the full fee and cannot charge the patient the difference between the
insurance payment and the provider's normal fee.
Access, - CORRECT ANSWER - The patient's ability to obtain medical care. The ease of
access is determined by such components as the availability of medical services and their
acceptability to the patient, the location of health care facilities, transportation, hours of
operation and cost of care.
Account Number, - CORRECT ANSWER - A number assigned to each account. This
number is used to identify the account and all charges and payments received.
Acute Care, - CORRECT ANSWER - Medical attention given to patients with conditions
of sudden onset that demand urgent attention or care of limited duration when the patient's health
and wellness would deteriorate without treatment. The care is generally short-term rather than
long-term or chronic care.
Acute Inpatient Care, - CORRECT ANSWER - A level of health care delivered to patients
experiencing acute illness or trauma. Acute care is generally short-term (< 30 days).
Add-Ons, - CORRECT ANSWER - Patients who are scheduled for services less than 24
hours in advance of the actual service time.
Adjustor , - CORRECT ANSWER - Insurance company representative.
Administrative Costs, - CORRECT ANSWER - Costs associated with creating and
submitting a bill for services, which could include: registration, utilization review, coding,
billing, and collection expenses.
,Admission Authorization, - CORRECT ANSWER - The process of third party payer
notification of urgent/emergent inpatient admission within specified time as determined by
payers (usually 24-48 hours or next business day).
Admission Date, - CORRECT ANSWER - The first date the patient entered the hospital
for a specific visit.
Admitting Diagnosis, - CORRECT ANSWER - Word, phrase, or International
Classification of Disease (ICD9) code used by the admitting physician to identify a condition or
disease from which a patient suffers and for which the patient needs or seeks medical care.
Admitting Physician, - CORRECT ANSWER - The physician who writes the order for the
patient to be admitted to the hospital. This physician must have admitting privileges at the
facility providing the healthcare services.
Advance Beneficiary Notice (ABN), - CORRECT ANSWER - A notice that a care
provider should give a Medicare beneficiary to sign if the services being provided may not be
considered medically necessary and Medicare may not pay for them. The advanced beneficiary
notice (ABN) allows the beneficiary to make an informed decision prior to services whether or
not he/she wishes to receive services. ABNs are not routinely given to emergency department
patients.
Advance Directive, - CORRECT ANSWER - An advance directive is a written instruction
relating to the provision of healthcare when a patient is incapacitated. It could include appointing
someone to make medical decisions, a statement expressing the patients wishes about anatomical
gifts (i.e. organ donation), and general statements about whether or not lifesustaining treatments
should be withheld or withdrawn.
Adverse Selection, - CORRECT ANSWER - Among applicants for a given group or
individual program, the tendency for those with an impaired health status, or who are prone to
higher than average utilization of benefits to be enrolled in disproportionate numbers and lower
deductible plans.
,Alias, - CORRECT ANSWER - An alias is a name by which the patient is also "known
as", or formerly known as.
All Patient Diagnosis Related Groups, - CORRECT ANSWER - A prospective hospital
claims reimbursement system currently utilized by the federal government Medicaid program
and the states of New York and New Jersey. APDRGs were designed to describe the complete
cross section of patients seen in Assignment of Benefits (APDRG) acute care hospitals.
Approximately 639 APDRGs are defined according to the principal diagnosis, secondary
diagnoses, procedures, age, birth weight, sex, discharge status. Each category has an established
fixed reimbursement rate based on average cost of treatment within a geographic area.
APRDRG's were developed to quantify the difference in demographic groups and clinical risk
factors for patients treated in hospitals. This proprietary grouping system's (i.e. 3M) purpose is to
obtain fair and accurate statistical comparisons between disparate populations and groups. Unlike
the Diagnosis Related Group (DRG) reimbursement system which is intended to capture
resource utilization intensity, the APRDRG system captures and relates the Severity of Illness
and Risk of Mortality factors present as a result of a patient's disease and disorders and the
interaction of those disorders. A form is signed by the Patient giving the healthcare provider
authority to bill his/her insurance plan and receive payment. The form is generally presented and
signed at the time of registration.
Alphanumeric - CORRECT ANSWER - Letters, numbers, punctuation marks and
mathematical symbols, as opposed to "numeric" which is numbers only. Term typically related
to the kind of data accepted in a computer field or in coding.
Ambulatory Care Patient, - CORRECT ANSWER - Patient receives medical or surgical
care in an outpatient setting that involves a broader, less specialized range of care. Ambulatory
patients are generally able to walk and are not confined to a bed. In a hospital setting, ambulatory
care generally refers to healthcare services provided on an outpatient basis.
Ambulatory Payment Classification (APC), - CORRECT ANSWER - A system of
averaging and bundling using Current Procedural Terminology (CPT) procedure codes,
Healthcare Common Procedure Coding System (HCPCS) Level II, and revenue codes submitted
for payment. The APC system utilizes groups of CPT codes based on clinical and resource
similarity and establishes payment rates for each APC grouping. The 650 + APCs are divided by
significant procedures, medical services, ancillary services and partial hospitalization services.
The APCs are similar clinically, by resources used and cost. A payment rate has been established
for each APC. System similar to Diagnosis Related Group's (DRG) to be used for outpatients.
, Current scheme includes 346 APCs broken into categories of Medical, Diagnostic, Surgical, and
Radiology and include Emergency Department and partial hospitalization services.
Ambulatory Surgical Center, - CORRECT ANSWER - A freestanding facility, other than
a physician's office, where surgical, diagnostic, and therapeutic services are provided on an
outpatient ambulatory basis.
Ancillary Services, - CORRECT ANSWER - A unit of the hospital, other than a nursing
unit, which provides medical services such as diagnostic testing, therapeutic procedures, or
dispenses medical products, such as medications or medical/surgical supplies. Examples:
Laboratory, Medical Imaging, Physical Therapy, Pharmacy. Ancillary is used to describe
diagnostic or therapeutic services, such as laboratory, radiology, pharmacy, or physical therapy,
performed by departments that do not have inpatient beds.
Annual Maximum Benefit Amount Deductible, - CORRECT ANSWER - The maximum
dollar amount set by a Managed Care Organization (MCO) that limits the total amount the plan
must pay for all health care services provided to a subscriber in a year. A deductible is the set
amount, per benefit year or period, the third party payer designates as the patient/guarantor's
responsibility. Usually the deductible must be paid before benefits will be paid by the payer. The
maximum dollar amount set by an MCO that limits the total amount the plan must pay for all
health care services provided to a subscriber in a year.
Appeal, - CORRECT ANSWER - An appeal is a special kind of complaint made when a
beneficiary or provider disagrees with decisions about health care services - typically related to
payment issues. There is usually a special process used to appeal payer decisions.
Appropriate Care, - CORRECT ANSWER - A diagnostic or treatment measure whose
expected health benefits exceed its expected health risks by a wide enough margin to justify the
measure.
Assignment of Benefits, - CORRECT ANSWER - Written authorization from the
policyholder for their insurance company to pay benefits directly to the care provider. Normally
acquired at the time of admission or registration.
Questions and CORRECT Answers
Accepting Assignment, - CORRECT ANSWER - When a provider agrees to accept the
allowable charges as the full fee and cannot charge the patient the difference between the
insurance payment and the provider's normal fee.
Access, - CORRECT ANSWER - The patient's ability to obtain medical care. The ease of
access is determined by such components as the availability of medical services and their
acceptability to the patient, the location of health care facilities, transportation, hours of
operation and cost of care.
Account Number, - CORRECT ANSWER - A number assigned to each account. This
number is used to identify the account and all charges and payments received.
Acute Care, - CORRECT ANSWER - Medical attention given to patients with conditions
of sudden onset that demand urgent attention or care of limited duration when the patient's health
and wellness would deteriorate without treatment. The care is generally short-term rather than
long-term or chronic care.
Acute Inpatient Care, - CORRECT ANSWER - A level of health care delivered to patients
experiencing acute illness or trauma. Acute care is generally short-term (< 30 days).
Add-Ons, - CORRECT ANSWER - Patients who are scheduled for services less than 24
hours in advance of the actual service time.
Adjustor , - CORRECT ANSWER - Insurance company representative.
Administrative Costs, - CORRECT ANSWER - Costs associated with creating and
submitting a bill for services, which could include: registration, utilization review, coding,
billing, and collection expenses.
,Admission Authorization, - CORRECT ANSWER - The process of third party payer
notification of urgent/emergent inpatient admission within specified time as determined by
payers (usually 24-48 hours or next business day).
Admission Date, - CORRECT ANSWER - The first date the patient entered the hospital
for a specific visit.
Admitting Diagnosis, - CORRECT ANSWER - Word, phrase, or International
Classification of Disease (ICD9) code used by the admitting physician to identify a condition or
disease from which a patient suffers and for which the patient needs or seeks medical care.
Admitting Physician, - CORRECT ANSWER - The physician who writes the order for the
patient to be admitted to the hospital. This physician must have admitting privileges at the
facility providing the healthcare services.
Advance Beneficiary Notice (ABN), - CORRECT ANSWER - A notice that a care
provider should give a Medicare beneficiary to sign if the services being provided may not be
considered medically necessary and Medicare may not pay for them. The advanced beneficiary
notice (ABN) allows the beneficiary to make an informed decision prior to services whether or
not he/she wishes to receive services. ABNs are not routinely given to emergency department
patients.
Advance Directive, - CORRECT ANSWER - An advance directive is a written instruction
relating to the provision of healthcare when a patient is incapacitated. It could include appointing
someone to make medical decisions, a statement expressing the patients wishes about anatomical
gifts (i.e. organ donation), and general statements about whether or not lifesustaining treatments
should be withheld or withdrawn.
Adverse Selection, - CORRECT ANSWER - Among applicants for a given group or
individual program, the tendency for those with an impaired health status, or who are prone to
higher than average utilization of benefits to be enrolled in disproportionate numbers and lower
deductible plans.
,Alias, - CORRECT ANSWER - An alias is a name by which the patient is also "known
as", or formerly known as.
All Patient Diagnosis Related Groups, - CORRECT ANSWER - A prospective hospital
claims reimbursement system currently utilized by the federal government Medicaid program
and the states of New York and New Jersey. APDRGs were designed to describe the complete
cross section of patients seen in Assignment of Benefits (APDRG) acute care hospitals.
Approximately 639 APDRGs are defined according to the principal diagnosis, secondary
diagnoses, procedures, age, birth weight, sex, discharge status. Each category has an established
fixed reimbursement rate based on average cost of treatment within a geographic area.
APRDRG's were developed to quantify the difference in demographic groups and clinical risk
factors for patients treated in hospitals. This proprietary grouping system's (i.e. 3M) purpose is to
obtain fair and accurate statistical comparisons between disparate populations and groups. Unlike
the Diagnosis Related Group (DRG) reimbursement system which is intended to capture
resource utilization intensity, the APRDRG system captures and relates the Severity of Illness
and Risk of Mortality factors present as a result of a patient's disease and disorders and the
interaction of those disorders. A form is signed by the Patient giving the healthcare provider
authority to bill his/her insurance plan and receive payment. The form is generally presented and
signed at the time of registration.
Alphanumeric - CORRECT ANSWER - Letters, numbers, punctuation marks and
mathematical symbols, as opposed to "numeric" which is numbers only. Term typically related
to the kind of data accepted in a computer field or in coding.
Ambulatory Care Patient, - CORRECT ANSWER - Patient receives medical or surgical
care in an outpatient setting that involves a broader, less specialized range of care. Ambulatory
patients are generally able to walk and are not confined to a bed. In a hospital setting, ambulatory
care generally refers to healthcare services provided on an outpatient basis.
Ambulatory Payment Classification (APC), - CORRECT ANSWER - A system of
averaging and bundling using Current Procedural Terminology (CPT) procedure codes,
Healthcare Common Procedure Coding System (HCPCS) Level II, and revenue codes submitted
for payment. The APC system utilizes groups of CPT codes based on clinical and resource
similarity and establishes payment rates for each APC grouping. The 650 + APCs are divided by
significant procedures, medical services, ancillary services and partial hospitalization services.
The APCs are similar clinically, by resources used and cost. A payment rate has been established
for each APC. System similar to Diagnosis Related Group's (DRG) to be used for outpatients.
, Current scheme includes 346 APCs broken into categories of Medical, Diagnostic, Surgical, and
Radiology and include Emergency Department and partial hospitalization services.
Ambulatory Surgical Center, - CORRECT ANSWER - A freestanding facility, other than
a physician's office, where surgical, diagnostic, and therapeutic services are provided on an
outpatient ambulatory basis.
Ancillary Services, - CORRECT ANSWER - A unit of the hospital, other than a nursing
unit, which provides medical services such as diagnostic testing, therapeutic procedures, or
dispenses medical products, such as medications or medical/surgical supplies. Examples:
Laboratory, Medical Imaging, Physical Therapy, Pharmacy. Ancillary is used to describe
diagnostic or therapeutic services, such as laboratory, radiology, pharmacy, or physical therapy,
performed by departments that do not have inpatient beds.
Annual Maximum Benefit Amount Deductible, - CORRECT ANSWER - The maximum
dollar amount set by a Managed Care Organization (MCO) that limits the total amount the plan
must pay for all health care services provided to a subscriber in a year. A deductible is the set
amount, per benefit year or period, the third party payer designates as the patient/guarantor's
responsibility. Usually the deductible must be paid before benefits will be paid by the payer. The
maximum dollar amount set by an MCO that limits the total amount the plan must pay for all
health care services provided to a subscriber in a year.
Appeal, - CORRECT ANSWER - An appeal is a special kind of complaint made when a
beneficiary or provider disagrees with decisions about health care services - typically related to
payment issues. There is usually a special process used to appeal payer decisions.
Appropriate Care, - CORRECT ANSWER - A diagnostic or treatment measure whose
expected health benefits exceed its expected health risks by a wide enough margin to justify the
measure.
Assignment of Benefits, - CORRECT ANSWER - Written authorization from the
policyholder for their insurance company to pay benefits directly to the care provider. Normally
acquired at the time of admission or registration.
