CHAM FINAL EXAM 2026/2027 QUESTIONS AND
SOLUTIONS RATED A+
✔✔Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) -
✔✔Civilian Health and Medical Program of the Uniformed Services has been replaced
by TRICARE.
✔✔Claim - ✔✔An itemized statement of healthcare services and their costs provided by
a hospital, physician's office or other provider facility. Submitted to the insurer or
managed care plan by either the plan member or the provider for payment of the costs
incurred.
✔✔Claimant - ✔✔The person or entity submitting a claim.
✔✔Claims Administration - ✔✔Employees in the claims administration department who
consider all the information pertinent to a claim and make decisions about the Managed
Care Organization's (MCO) payment of the claim. Also known as claims analysts.
✔✔Clinic - ✔✔A medical or surgical specialty unit of a hospital or hospitals' free-
standing where a patient is seen on a ambulatory basis but remains the hospital's
responsibility for ongoing care and disposition.
✔✔Clinical Data Repository (CDR) - ✔✔The processing of receiving, reviewing,
adjudicating and processing claims.
✔✔Clinical Integration - ✔✔A type of operational integration that enables patients to
receive a variety of health services from the same organization or entity, which
streamlines administrative processes and increases the potential for the delivery of high
quality healthcare.
✔✔Closed Access - ✔✔A provision that specifies that plan members must obtain
medical services only from network providers through a primary care physician to
receive benefits.
✔✔CMS 1450 (UB-04) - ✔✔A revised version of the UB-92, a federal directive requiring
a hospital to follow specific billing procedures, itemizing all services included and billed
for on each invoice.Uniform bill mandated by thr Centers for Medicare and Medicaid
Services (CMS) for use by hospitals, skilled nursing facilities, home health agencies,
community mental health facilities, etc.
✔✔Co-Insurance - ✔✔Another amount the third party payer can identify as the
patient/guarantor's responsibility. Usually a percentage of the total billed amount.
,✔✔Co-Insurance Days (CID) - ✔✔A method of cost sharing in which the subscriber is
responsible for a specified percentage of the cost of healthcare under fee for service
plans. Plans where the insured is responsible for 20% while the insurance covers 80%
are fairly typical. Frequently, there is a maximum amount the insured is required to pay,
called a "stop loss amount". _______ relate to Part A Medicare benefits. For each day
of hospitalization over 60 days and up to the 90th day, a co-insurance payment of one-
quarter of the inpatient deductible is due.
✔✔Collection Agency - ✔✔An outside vendor that collects payment on hospital
accounts under contract with the hospital.
✔✔Commercial Insurance - ✔✔The term is used to identify several types of insurance
policies other than managed care. Most policies provide coverage in the following four
areas: hospitalization, surgery, minor medical and major medical.
✔✔Common Working File (CWF) - ✔✔A national file of Medicare claims.
✔✔Co-Morbidity - ✔✔a pre-existing condition that will, because of its presence with a
specific principal diagnosis, cause an increased length of stay by at least one day. Also
referred to as a "substantial complication".
✔✔Compliance - ✔✔The act of complying with a request, demand or regulation. Also
known as Corporate Integrity. Conducting ourselves within the law in all our business
practices. Addressing such issues as, but not limited to:Fraud and Abuse, Billing
Practices, Antitrust, Quality of Care, Managed Care, Bribes and Improper Payments,
Conflicts of Interest, Environments Concerns, and Copyright and Software Licensing.
✔✔Consent - ✔✔Voluntary permission or agreement.
✔✔Consent to Treat - ✔✔The patient's or legally responsible party's signed
authorization for a hospital to provide medical care and treatment.
✔✔Conservator - ✔✔A person, official,or institution designated to take over and protect
the interests of an incompetent person. This includes being responsible for paying the
individual's healthcare bills. A guardian may also be the conservator.
✔✔Consolidated Omnibus Budget Reconciliation Act (COBRA) - ✔✔Requires
employers to permit employees or family members to continue their group health
insurance coverage at their own expense, but at group rates, if they lose coverage
because of loss of employment, divorce, death of the supporting spouse or other
designated events. Former employees may be required to pay a two percent
administrative fee in addition to the full premium; this coverage generally last a
maximum of 18 months.
, ✔✔Consulting Physician - ✔✔A physician other than the admitting or attending
physician, who has been asked to participate or provide counsel in a particular episode
of care.
✔✔Consumer Driven Healthcare - ✔✔Refers to health plans in which individuals have a
personal health savings account (HSA) or a health reimbursement account (HRA) from
which they pay medical expenses.
✔✔Continuum of Care - ✔✔The scope of healthcare services provided to an individual
during a single episode of illness or for multiple conditions over a lifetime.
✔✔Contract - ✔✔A legal agreement between a payer and a subscribing group of
individual that specifies rate, performance covenants, the relationship among the
parties, schedule benefits and other pertinent conditions. Usually limited to a 12 month
period.
✔✔Contract Provider - ✔✔Any hospital, skilled nursing facility, extended care facility,
individual. organization or agency licenses that has a contractual arrangement with an
insurer for the provision of services under an insurance contract.
✔✔Contractual Allowance - ✔✔The amount that is not paid, due to a reimbursement
agreement. This is an allowance that may not be paid by any party. It is based on a
contractual agreement between the third party payer and the hospital.
✔✔Coordination of Benefits - ✔✔The determination of primary, secondary and tertiary
payers must be completed either at registration or through the insurance verification
process. Determining the priority of payment of benefits to eliminate duplicate
payments. Applies when an insured is covered by more than one policy. It stipulates
that the involved insurers will each pay their share of the insured's total covered
expenses, but will not pay in total more than those expenses.
✔✔Co-Pay - ✔✔A cost sharing arrangement wherein the patient/guarantor is
responsible for a defined amount for a specific type of service. Usually paid at the time
of service.
✔✔Co-Pay CMS 1500 - ✔✔A fixed amount that the beneficiary pays for healthcare
services, regardless of the actual charge; the amount is designated by an insurer as the
patient's responsibility. Most health maintenance organizations (HMO) and preferred
provider organizations (PPO) have co-pays for emergency and urgent care visits; many
waive the co-pay if the patient is admitted. Some insurance companies call this cost-
share. CMS 1500 is used by physicians and other clinicians.
✔✔Corporate Person Index (CPI) - ✔✔houses the patient's medical record number and
any other key demographic information.
SOLUTIONS RATED A+
✔✔Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) -
✔✔Civilian Health and Medical Program of the Uniformed Services has been replaced
by TRICARE.
✔✔Claim - ✔✔An itemized statement of healthcare services and their costs provided by
a hospital, physician's office or other provider facility. Submitted to the insurer or
managed care plan by either the plan member or the provider for payment of the costs
incurred.
✔✔Claimant - ✔✔The person or entity submitting a claim.
✔✔Claims Administration - ✔✔Employees in the claims administration department who
consider all the information pertinent to a claim and make decisions about the Managed
Care Organization's (MCO) payment of the claim. Also known as claims analysts.
✔✔Clinic - ✔✔A medical or surgical specialty unit of a hospital or hospitals' free-
standing where a patient is seen on a ambulatory basis but remains the hospital's
responsibility for ongoing care and disposition.
✔✔Clinical Data Repository (CDR) - ✔✔The processing of receiving, reviewing,
adjudicating and processing claims.
✔✔Clinical Integration - ✔✔A type of operational integration that enables patients to
receive a variety of health services from the same organization or entity, which
streamlines administrative processes and increases the potential for the delivery of high
quality healthcare.
✔✔Closed Access - ✔✔A provision that specifies that plan members must obtain
medical services only from network providers through a primary care physician to
receive benefits.
✔✔CMS 1450 (UB-04) - ✔✔A revised version of the UB-92, a federal directive requiring
a hospital to follow specific billing procedures, itemizing all services included and billed
for on each invoice.Uniform bill mandated by thr Centers for Medicare and Medicaid
Services (CMS) for use by hospitals, skilled nursing facilities, home health agencies,
community mental health facilities, etc.
✔✔Co-Insurance - ✔✔Another amount the third party payer can identify as the
patient/guarantor's responsibility. Usually a percentage of the total billed amount.
,✔✔Co-Insurance Days (CID) - ✔✔A method of cost sharing in which the subscriber is
responsible for a specified percentage of the cost of healthcare under fee for service
plans. Plans where the insured is responsible for 20% while the insurance covers 80%
are fairly typical. Frequently, there is a maximum amount the insured is required to pay,
called a "stop loss amount". _______ relate to Part A Medicare benefits. For each day
of hospitalization over 60 days and up to the 90th day, a co-insurance payment of one-
quarter of the inpatient deductible is due.
✔✔Collection Agency - ✔✔An outside vendor that collects payment on hospital
accounts under contract with the hospital.
✔✔Commercial Insurance - ✔✔The term is used to identify several types of insurance
policies other than managed care. Most policies provide coverage in the following four
areas: hospitalization, surgery, minor medical and major medical.
✔✔Common Working File (CWF) - ✔✔A national file of Medicare claims.
✔✔Co-Morbidity - ✔✔a pre-existing condition that will, because of its presence with a
specific principal diagnosis, cause an increased length of stay by at least one day. Also
referred to as a "substantial complication".
✔✔Compliance - ✔✔The act of complying with a request, demand or regulation. Also
known as Corporate Integrity. Conducting ourselves within the law in all our business
practices. Addressing such issues as, but not limited to:Fraud and Abuse, Billing
Practices, Antitrust, Quality of Care, Managed Care, Bribes and Improper Payments,
Conflicts of Interest, Environments Concerns, and Copyright and Software Licensing.
✔✔Consent - ✔✔Voluntary permission or agreement.
✔✔Consent to Treat - ✔✔The patient's or legally responsible party's signed
authorization for a hospital to provide medical care and treatment.
✔✔Conservator - ✔✔A person, official,or institution designated to take over and protect
the interests of an incompetent person. This includes being responsible for paying the
individual's healthcare bills. A guardian may also be the conservator.
✔✔Consolidated Omnibus Budget Reconciliation Act (COBRA) - ✔✔Requires
employers to permit employees or family members to continue their group health
insurance coverage at their own expense, but at group rates, if they lose coverage
because of loss of employment, divorce, death of the supporting spouse or other
designated events. Former employees may be required to pay a two percent
administrative fee in addition to the full premium; this coverage generally last a
maximum of 18 months.
, ✔✔Consulting Physician - ✔✔A physician other than the admitting or attending
physician, who has been asked to participate or provide counsel in a particular episode
of care.
✔✔Consumer Driven Healthcare - ✔✔Refers to health plans in which individuals have a
personal health savings account (HSA) or a health reimbursement account (HRA) from
which they pay medical expenses.
✔✔Continuum of Care - ✔✔The scope of healthcare services provided to an individual
during a single episode of illness or for multiple conditions over a lifetime.
✔✔Contract - ✔✔A legal agreement between a payer and a subscribing group of
individual that specifies rate, performance covenants, the relationship among the
parties, schedule benefits and other pertinent conditions. Usually limited to a 12 month
period.
✔✔Contract Provider - ✔✔Any hospital, skilled nursing facility, extended care facility,
individual. organization or agency licenses that has a contractual arrangement with an
insurer for the provision of services under an insurance contract.
✔✔Contractual Allowance - ✔✔The amount that is not paid, due to a reimbursement
agreement. This is an allowance that may not be paid by any party. It is based on a
contractual agreement between the third party payer and the hospital.
✔✔Coordination of Benefits - ✔✔The determination of primary, secondary and tertiary
payers must be completed either at registration or through the insurance verification
process. Determining the priority of payment of benefits to eliminate duplicate
payments. Applies when an insured is covered by more than one policy. It stipulates
that the involved insurers will each pay their share of the insured's total covered
expenses, but will not pay in total more than those expenses.
✔✔Co-Pay - ✔✔A cost sharing arrangement wherein the patient/guarantor is
responsible for a defined amount for a specific type of service. Usually paid at the time
of service.
✔✔Co-Pay CMS 1500 - ✔✔A fixed amount that the beneficiary pays for healthcare
services, regardless of the actual charge; the amount is designated by an insurer as the
patient's responsibility. Most health maintenance organizations (HMO) and preferred
provider organizations (PPO) have co-pays for emergency and urgent care visits; many
waive the co-pay if the patient is admitted. Some insurance companies call this cost-
share. CMS 1500 is used by physicians and other clinicians.
✔✔Corporate Person Index (CPI) - ✔✔houses the patient's medical record number and
any other key demographic information.
