CHAA EVALUATION QUESTIONS AND ANSWERS SET
A+
✔✔RC21. What is the tracking code for patients admitted as inpatients to the hospital
but do not meet the criteria?
a. Condition Code 44
b. CMS Code 22
c. Inpatient Code 17 - ✔✔A
✔✔RC22. Who is the primary payer when the Medicare patient is under the age of 65
and is covered by their spouses BCBS plan through the Federal Government?
a. Medicare
b. BCBS
c. Federal Health Benefit Plan - ✔✔B
✔✔RC23. What is the time period when a Medicare patient on ESRD's group health
plan is the primary payer?
a. 3-month coordination period
b. COBRA
c. 30-month coordination period - ✔✔C
✔✔RC24. Methodology used to determine income eligibility for Medicaid:
a. MAGI
b. Dual Eligibility Standards
c. FPL 133 - ✔✔A
✔✔RC25. Name given when a provider screens a patient for temporary Medicaid
coverage:
a. Temporary CV
b. Presumptive Eligibility
c. Self-Attestation Coverage Period - ✔✔B
,✔✔Revenue Cycle - ✔✔Revenue cycle is a term for the life of a patient account from
creation to resolution. It reflects all the operational components under which a medical
facility is reimbursed for services rendered to its patients.
✔✔Components of revenue cycle include: - ✔✔Scheduling
-Pre-registration
-Financial pre-requisites
-Medical necessity
-Arrival
-Registration
-Wayfinding
-Discharge
-Q/A-billing pre-requisites
-MR coding
-Billing
-Collections
-Bad debt.
✔✔With respect to access, most reimbursement falls into one of three categories: - ✔✔-
Third patient commercial or government-sponsored payers (i.e., Blue Cross, Aetna,
Medicare, Medicaid, Tricare)
-Other programs such as Worker's Compensation, research grants, clinical trials and
studies, service contracts with employers, etc.
-Patient payments
-In addition, medical facilities provide uncompensated and under-compensated care to
patients who qualify for various charity programs and write-offs, plus unpaid balances
that eventually go to bad debt.
✔✔Account flow through the revenue cycle influences several critical elements: - ✔✔-
Completeness and accuracy of patient demographic and financial information to ensure
correct patient identity and billing.
-Completeness and accuracy of clinical information taken at time of scheduling.
-Medical necessity determination.
-Financial clearance to determine if and how the account will be paid.
-Proper completion of forms and signatures for compliance.
✔✔Access should be aware of and meet these standards regarding 3rd party billing: -
✔✔-Precertification
-Medical necessity
-Correct diagnosis/CPT codes
-Accurate patient/insured name as it appears in payer's records
-Accurate policy, group and payer ID numbers
*Some payers only allow one chance to fix a claim before it cannot be reimbursed, and
claims submitted after the allowed time frame, potentially due to incomplete or
,inaccurate data, means the claim cannot be reimbursed and is lost revenue for the
organization.
✔✔Patient-owed balances fall into two general categories: - ✔✔-Accounts where
patients have no third-party insurance or other coverage and do not qualify for charity or
other assistance (aka True Self-Pay)
-Balances owed by patients before or after insurance pays
✔✔Ambulatory Payment Classifications (APCs) - ✔✔For professional services and
most outpatient services performed at a hospital, Medicare pays by Ambulatory
Payment Classifications (APCs). APCs are tied to CPT (Current Procedural
Terminology) codes, which are used for coding procedures. The payment rate
established for each APC is calculated based on the national average cost (operating
and capital) of the hospitals.
✔✔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 is mandated by the Centers for Medicare and
Medicaid Services (CMS) for use by hospitals, skilled nursing facilities, home health
agencies, community mental health facilities, etc. "Form locator" is the name of the data
fields on each of the uniform bills (i.e., UB-04). The UB-04 has 81 numerically
sequenced form locators, while the 1500 has 33 form locators. Sometimes the form
locators are referred to as boxes, such as Box 1, Box 4.
✔✔Co-pay CMS 1500: - ✔✔CMS 1500 is used by physicians and other clinicians. It is 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 (HMOs) and preferred provider organizations (PPOs)
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."
✔✔In accordance with Section 501(r) regulations through the Affordable Care Act, a
hospital must: - ✔✔Establish a written financial assistance policy and make it available
to patients. A financial counselor can help determine what financial assistance is
available to a patient and apply for financial help.
✔✔Out-of-Pocket Maximum - ✔✔The total payments toward eligible expenses that a
covered person funds for him/herself and/or dependents. These expenses may include
deductibles, copays and coinsurance as defined by the contract. Once this limit is
reached, benefits will increase to 100 percent for health services received during the
rest of that calendar or policy year. Deductibles may or may not be included in out-of-
pocket limits.
✔✔Coinsurance - ✔✔The percentage amount that is payable, per policy provisions,
toward medical costs after the deductible has been met. For example, a patient's
, coinsurance amount may be 20 percent, and the insurance company's coinsurance
could be 80 percent under a contract.
✔✔Coordination of benefits (COB) - ✔✔Is a way of determining the order in which
benefits are paid, and the amounts that are payable, when a patient is covered by more
than one health plan. It is intended to prevent duplication of payments when a patient is
covered by multiple group health plans for the same medical service.
✔✔NAIC - ✔✔National Association of Insurance Commissioners (NAIC)
✔✔Birthday Rule: - ✔✔According to the birthday rule, the primary plan for a child is the
health plan of the parent whose birthday comes first in the calendar year. Remember
this is the date, not the year. If both birthdays fall on the same day, then the plan that
has been in effect longer is primary.
For example:
Timothy's mother's birthday is January 27, 1985. Timothy's father's birthday is March 4,
1983. The mother's insurance would be primary for Timothy because her birthday
occurs first in the calendar year.
✔✔When the parents are not together and there is no court decree or healthcare
coverage stipulation, the benefits for the child are determined in the following order: -
✔✔-The plan of the parent with custody of the child is primary.
-The plan of the stepparent (spouse of the parent with custody) is primary.
-The plan of the parent who does not have custody is primary.
-The plan of the stepparent (spouse of the non-custodial parent) is primary.
✔✔When a patient has more than one insurance: - ✔✔-The primary plan is contacted
for authorization and billed for all services rendered. They make the first payment as if
no other coverage existed except this plan.
-The secondary plan is billed after the primary plan has made the maximum payment
allowable on eligible expenses. The secondary carrier calculates benefits as though
there was no other coverage. They then pay the lesser of the calculated amount and the
balance the primary carrier has submitted.
✔✔Point-of-service (POS) collection - ✔✔Point-of-service (POS) collection means
collecting the patient's portion of the bill at the time service is rendered.
-EMTALA mandated that patients presenting for emergency service must have a
medical screening exam and be medically stable before we can ask for payment.
-Third-Party Payers - always discuss payment with the patient or spouse, unless the
patient has given written permission to discuss payment with the third party.
-CMS Guidelines mandates that collection policies used for Medicare patients be
consistent with the policies for any other patient.
A+
✔✔RC21. What is the tracking code for patients admitted as inpatients to the hospital
but do not meet the criteria?
a. Condition Code 44
b. CMS Code 22
c. Inpatient Code 17 - ✔✔A
✔✔RC22. Who is the primary payer when the Medicare patient is under the age of 65
and is covered by their spouses BCBS plan through the Federal Government?
a. Medicare
b. BCBS
c. Federal Health Benefit Plan - ✔✔B
✔✔RC23. What is the time period when a Medicare patient on ESRD's group health
plan is the primary payer?
a. 3-month coordination period
b. COBRA
c. 30-month coordination period - ✔✔C
✔✔RC24. Methodology used to determine income eligibility for Medicaid:
a. MAGI
b. Dual Eligibility Standards
c. FPL 133 - ✔✔A
✔✔RC25. Name given when a provider screens a patient for temporary Medicaid
coverage:
a. Temporary CV
b. Presumptive Eligibility
c. Self-Attestation Coverage Period - ✔✔B
,✔✔Revenue Cycle - ✔✔Revenue cycle is a term for the life of a patient account from
creation to resolution. It reflects all the operational components under which a medical
facility is reimbursed for services rendered to its patients.
✔✔Components of revenue cycle include: - ✔✔Scheduling
-Pre-registration
-Financial pre-requisites
-Medical necessity
-Arrival
-Registration
-Wayfinding
-Discharge
-Q/A-billing pre-requisites
-MR coding
-Billing
-Collections
-Bad debt.
✔✔With respect to access, most reimbursement falls into one of three categories: - ✔✔-
Third patient commercial or government-sponsored payers (i.e., Blue Cross, Aetna,
Medicare, Medicaid, Tricare)
-Other programs such as Worker's Compensation, research grants, clinical trials and
studies, service contracts with employers, etc.
-Patient payments
-In addition, medical facilities provide uncompensated and under-compensated care to
patients who qualify for various charity programs and write-offs, plus unpaid balances
that eventually go to bad debt.
✔✔Account flow through the revenue cycle influences several critical elements: - ✔✔-
Completeness and accuracy of patient demographic and financial information to ensure
correct patient identity and billing.
-Completeness and accuracy of clinical information taken at time of scheduling.
-Medical necessity determination.
-Financial clearance to determine if and how the account will be paid.
-Proper completion of forms and signatures for compliance.
✔✔Access should be aware of and meet these standards regarding 3rd party billing: -
✔✔-Precertification
-Medical necessity
-Correct diagnosis/CPT codes
-Accurate patient/insured name as it appears in payer's records
-Accurate policy, group and payer ID numbers
*Some payers only allow one chance to fix a claim before it cannot be reimbursed, and
claims submitted after the allowed time frame, potentially due to incomplete or
,inaccurate data, means the claim cannot be reimbursed and is lost revenue for the
organization.
✔✔Patient-owed balances fall into two general categories: - ✔✔-Accounts where
patients have no third-party insurance or other coverage and do not qualify for charity or
other assistance (aka True Self-Pay)
-Balances owed by patients before or after insurance pays
✔✔Ambulatory Payment Classifications (APCs) - ✔✔For professional services and
most outpatient services performed at a hospital, Medicare pays by Ambulatory
Payment Classifications (APCs). APCs are tied to CPT (Current Procedural
Terminology) codes, which are used for coding procedures. The payment rate
established for each APC is calculated based on the national average cost (operating
and capital) of the hospitals.
✔✔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 is mandated by the Centers for Medicare and
Medicaid Services (CMS) for use by hospitals, skilled nursing facilities, home health
agencies, community mental health facilities, etc. "Form locator" is the name of the data
fields on each of the uniform bills (i.e., UB-04). The UB-04 has 81 numerically
sequenced form locators, while the 1500 has 33 form locators. Sometimes the form
locators are referred to as boxes, such as Box 1, Box 4.
✔✔Co-pay CMS 1500: - ✔✔CMS 1500 is used by physicians and other clinicians. It is 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 (HMOs) and preferred provider organizations (PPOs)
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."
✔✔In accordance with Section 501(r) regulations through the Affordable Care Act, a
hospital must: - ✔✔Establish a written financial assistance policy and make it available
to patients. A financial counselor can help determine what financial assistance is
available to a patient and apply for financial help.
✔✔Out-of-Pocket Maximum - ✔✔The total payments toward eligible expenses that a
covered person funds for him/herself and/or dependents. These expenses may include
deductibles, copays and coinsurance as defined by the contract. Once this limit is
reached, benefits will increase to 100 percent for health services received during the
rest of that calendar or policy year. Deductibles may or may not be included in out-of-
pocket limits.
✔✔Coinsurance - ✔✔The percentage amount that is payable, per policy provisions,
toward medical costs after the deductible has been met. For example, a patient's
, coinsurance amount may be 20 percent, and the insurance company's coinsurance
could be 80 percent under a contract.
✔✔Coordination of benefits (COB) - ✔✔Is a way of determining the order in which
benefits are paid, and the amounts that are payable, when a patient is covered by more
than one health plan. It is intended to prevent duplication of payments when a patient is
covered by multiple group health plans for the same medical service.
✔✔NAIC - ✔✔National Association of Insurance Commissioners (NAIC)
✔✔Birthday Rule: - ✔✔According to the birthday rule, the primary plan for a child is the
health plan of the parent whose birthday comes first in the calendar year. Remember
this is the date, not the year. If both birthdays fall on the same day, then the plan that
has been in effect longer is primary.
For example:
Timothy's mother's birthday is January 27, 1985. Timothy's father's birthday is March 4,
1983. The mother's insurance would be primary for Timothy because her birthday
occurs first in the calendar year.
✔✔When the parents are not together and there is no court decree or healthcare
coverage stipulation, the benefits for the child are determined in the following order: -
✔✔-The plan of the parent with custody of the child is primary.
-The plan of the stepparent (spouse of the parent with custody) is primary.
-The plan of the parent who does not have custody is primary.
-The plan of the stepparent (spouse of the non-custodial parent) is primary.
✔✔When a patient has more than one insurance: - ✔✔-The primary plan is contacted
for authorization and billed for all services rendered. They make the first payment as if
no other coverage existed except this plan.
-The secondary plan is billed after the primary plan has made the maximum payment
allowable on eligible expenses. The secondary carrier calculates benefits as though
there was no other coverage. They then pay the lesser of the calculated amount and the
balance the primary carrier has submitted.
✔✔Point-of-service (POS) collection - ✔✔Point-of-service (POS) collection means
collecting the patient's portion of the bill at the time service is rendered.
-EMTALA mandated that patients presenting for emergency service must have a
medical screening exam and be medically stable before we can ask for payment.
-Third-Party Payers - always discuss payment with the patient or spouse, unless the
patient has given written permission to discuss payment with the third party.
-CMS Guidelines mandates that collection policies used for Medicare patients be
consistent with the policies for any other patient.
