CRC FINAL EXAM NEWEST 2025 ACTUAL EXAM
COMPLETE EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
ALREADY GRADED A+.
How is predictive modeling used in risk adjustment? - CORRECT ANS>>to determine
suspected diagnosis based on data elements.
Which of the following data elements are used in predictive modeling?
DME claims
Prescription drug events
Physician claims data
Facility claims data
- CORRECT ANS>>d. I, II, III, and IV
What might happen as a result of predictive modeling?
- CORRECT ANS>>a. Disease management programs
In the CMS Star Ratings program, which measure is given the highest weight?
- CORRECT ANS>>a. Outcomes
How often are HEDIS measures revised?
- CORRECT ANS>>d. Annually
Which statement is TRUE regarding the CMS Stars quality rating system?
- CORRECT ANS>>b. Quality bonus payments are made to Medicare Advantage plans
who score at least four stars.
Merit-based Incentive Payment System (MIPS) includes which performance categories?
Promoting Interoperability
Cost
Improvement Activities
Quantity
Quality
- CORRECT ANS>>c. I, II, III, and V
Which of the following are domains in CMS Part C & D Stars Rating?
Staying Healthy
Managing Chronic Conditions
Member Experience with Health Plans
Member Complaints, Problems Getting Services, and Improvement in the Health Plan's
,Performance
Health Plan Customer Service
- CORRECT ANS>>c. I, II, III, IV and V
What is the participation tracks available through Medicare Access and CHIP
Reauthorization Act (MACRA)?
Merit-based Incentive Payment Systems
Sustainable Growth System
Advanced Alternative Payment Models
- CORRECT ANS>>c. I and III
What is predictive modeling?
- CORRECT ANS>>a. An analytical review of known data elements to establish a
hypothesis related to the future health of patients.
Who developed and maintains HEDIS?
- CORRECT ANS>>d. NCQA
What do the Star Ratings identify?
- CORRECT ANS>>a. Top performing health plans based on quality
What is the goal of HEDIS?
- ANSWER >>>>b. Allow patients to compare health plans.
When are Star Ratings are publicly published?
- CORRECT ANS>>c. October of each year.
How is predictive modeling used in risk adjustment?
- CORRECT ANS>>b. Determine suspected diagnoses based on data elements.
If you were using predictive modeling and the results were:
Rx Claim: Albuterol (quick-relief inhaler)
Medical Claim: Pulmonary Function Test
DME claim: Home Nebulizer
- CORRECT ANS>>b. Asthma
If you were using a predictive model and the results were:
The member had a DME claim for a cane.
The member had an Rx Claim for a Fosamax.
The member had a medical claim for a bone density scan. Which diagnosis would you
predict this member has?
- CORRECT ANS>>d. Osteoporosis
, Which statement is TRUE regarding predictive modeling?
- CORRECT ANS>>b. Health plans often use predictive modeling to anticipate potential
future diagnoses for an individual patient.
How is HEDIS data collected?
- CORRECT ANS>>all of the above
Predictive modeling can use many data elements. Which are beneficial for identifying a
person with diabetes?
Rx claims
Medical claims
DME claims
- CORRECT ANS>>d. I, II, and III
Which type of documentation can be used to support diagnoses reported under risk
adjustment models?
- CORRECT ANS>>a. Inpatient admission note
Which statement is TRUE regarding diagnosis codes and assigned HCCs?
- CORRECT ANS>>c. not all diagnosis codes are assigned an HCC
Where can a list of diagnosis mappings to HCCs be located?
- CORRECT ANS>>b. CMS website.
Which of the following is TRUE regarding the risk adjustment model by HHS?
- CORRECT ANS>>b. States can either use the federal methodology or propose an
alternate for certification by HHS.
When reporting a code for retinopathy, must the coder find documentation from an
ophthalmologist in order to code the condition as an active condition?
- CORRECT ANS>>c. No, any approved provider can validate any diagnosis.
Under the Affordable Care Act (ACA), can health plans change the premium rate based
on a patient's health status where patients with more complex medical issues are
required to pay a higher premium than patients with less complex medical issues?
- CORRECT ANS>>c. No, health plans cannot charge different premiums based on
health status.
How often is the normalization factor adjusted?
- CORRECT ANS>>c. yearly
RA must be compared to average FFS expenses and rates. The purpose of the FFS
normalization adjustment issue that CMS payments are based on a population with an
average
COMPLETE EXAM QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
ALREADY GRADED A+.
How is predictive modeling used in risk adjustment? - CORRECT ANS>>to determine
suspected diagnosis based on data elements.
Which of the following data elements are used in predictive modeling?
DME claims
Prescription drug events
Physician claims data
Facility claims data
- CORRECT ANS>>d. I, II, III, and IV
What might happen as a result of predictive modeling?
- CORRECT ANS>>a. Disease management programs
In the CMS Star Ratings program, which measure is given the highest weight?
- CORRECT ANS>>a. Outcomes
How often are HEDIS measures revised?
- CORRECT ANS>>d. Annually
Which statement is TRUE regarding the CMS Stars quality rating system?
- CORRECT ANS>>b. Quality bonus payments are made to Medicare Advantage plans
who score at least four stars.
Merit-based Incentive Payment System (MIPS) includes which performance categories?
Promoting Interoperability
Cost
Improvement Activities
Quantity
Quality
- CORRECT ANS>>c. I, II, III, and V
Which of the following are domains in CMS Part C & D Stars Rating?
Staying Healthy
Managing Chronic Conditions
Member Experience with Health Plans
Member Complaints, Problems Getting Services, and Improvement in the Health Plan's
,Performance
Health Plan Customer Service
- CORRECT ANS>>c. I, II, III, IV and V
What is the participation tracks available through Medicare Access and CHIP
Reauthorization Act (MACRA)?
Merit-based Incentive Payment Systems
Sustainable Growth System
Advanced Alternative Payment Models
- CORRECT ANS>>c. I and III
What is predictive modeling?
- CORRECT ANS>>a. An analytical review of known data elements to establish a
hypothesis related to the future health of patients.
Who developed and maintains HEDIS?
- CORRECT ANS>>d. NCQA
What do the Star Ratings identify?
- CORRECT ANS>>a. Top performing health plans based on quality
What is the goal of HEDIS?
- ANSWER >>>>b. Allow patients to compare health plans.
When are Star Ratings are publicly published?
- CORRECT ANS>>c. October of each year.
How is predictive modeling used in risk adjustment?
- CORRECT ANS>>b. Determine suspected diagnoses based on data elements.
If you were using predictive modeling and the results were:
Rx Claim: Albuterol (quick-relief inhaler)
Medical Claim: Pulmonary Function Test
DME claim: Home Nebulizer
- CORRECT ANS>>b. Asthma
If you were using a predictive model and the results were:
The member had a DME claim for a cane.
The member had an Rx Claim for a Fosamax.
The member had a medical claim for a bone density scan. Which diagnosis would you
predict this member has?
- CORRECT ANS>>d. Osteoporosis
, Which statement is TRUE regarding predictive modeling?
- CORRECT ANS>>b. Health plans often use predictive modeling to anticipate potential
future diagnoses for an individual patient.
How is HEDIS data collected?
- CORRECT ANS>>all of the above
Predictive modeling can use many data elements. Which are beneficial for identifying a
person with diabetes?
Rx claims
Medical claims
DME claims
- CORRECT ANS>>d. I, II, and III
Which type of documentation can be used to support diagnoses reported under risk
adjustment models?
- CORRECT ANS>>a. Inpatient admission note
Which statement is TRUE regarding diagnosis codes and assigned HCCs?
- CORRECT ANS>>c. not all diagnosis codes are assigned an HCC
Where can a list of diagnosis mappings to HCCs be located?
- CORRECT ANS>>b. CMS website.
Which of the following is TRUE regarding the risk adjustment model by HHS?
- CORRECT ANS>>b. States can either use the federal methodology or propose an
alternate for certification by HHS.
When reporting a code for retinopathy, must the coder find documentation from an
ophthalmologist in order to code the condition as an active condition?
- CORRECT ANS>>c. No, any approved provider can validate any diagnosis.
Under the Affordable Care Act (ACA), can health plans change the premium rate based
on a patient's health status where patients with more complex medical issues are
required to pay a higher premium than patients with less complex medical issues?
- CORRECT ANS>>c. No, health plans cannot charge different premiums based on
health status.
How often is the normalization factor adjusted?
- CORRECT ANS>>c. yearly
RA must be compared to average FFS expenses and rates. The purpose of the FFS
normalization adjustment issue that CMS payments are based on a population with an
average
