CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) ACTUAL
EXAM QUESTIONS AND ANSWERS (VERIFIED AND WELL DETAILED
ANSWERS) LATEST 2025/2026
The No Surprise Act was a product of:
A) The Health Insurance Portability Act
B) The Consolidation Appropriations Act
C) The Treaty of Algeron
D) The Affordable Care Act - CORRECT ANSWERS - D) The Affordable Care
Act
Which of the following is an advantage of direct contracting?
A) Providers do not have to adjudicate claims for payment
B) Employers can save the cost of working with an insurance company
C) It allows the patients to have a choice of providers and physicians
D) Providers can work directly with employers to reduce the cost of providing
insurance - CORRECT ANSWERS - D) Providers can work directly with
employers to reduce the cost of providing insurance
Accountable Care Organizations (ACOs) have all of the following characteristics
EXCEPT:
,A) Patient centric care model
B) Financial incentive for quantity of care
C) Integrated care coordination
D) Electronic Medical Record System - CORRECT ANSWERS - B) Financial
incentive for quantity of care
The Emergency Treatment and Active Labor Act (EMTALA) governs when a
patient may be transferred from one hospital to another when in a(n) condition:
A) Life threatening
B) Non-emergency
C) Stable
D) Chronic - CORRECT ANSWERS - A) Life threatening
STAR ratings are used to indicate the quality of:
A) Accountable Care Organizations performance
B) Medicare Advantage health plan performance
C) Services provided by hospitals
D) Services provided by physicians - CORRECT ANSWERS - B) Medicare
Advantage health plan performance
To evaluate an organization's compliance with the CMS COP standards and other
accreditation requirements, is the purpose of:
,A) A comprehensive accreditation process
B) Recovery Audits
C) The American Osteopathic Association
D) A clean claim - CORRECT ANSWERS - A) A comprehensive accreditation
process
What is tiering?
A) Typically fixed dollar amounts paid by the insured directly to the practitioner
per episode of care
B) Healthcare coverage products featuring narrow networks, high cost sharing and
very low premiums
C) An effort by insurers to increase premiums and to address calls from employers
and the public for improved quality
D) The ranking or classifying of one or more of the provider delivery system
components to influence choice - CORRECT ANSWERS - D) The ranking or
classifying of one or more of the provider delivery system components to influence
choice
Which piece of information is NOT necessary for claims processing?
A) Provider or referring provider identification
B) Family medical history
, C) Type of service
D) Procedure code - CORRECT ANSWERS - B) Family medical history
Which option is NOT true concerning the Consolidated Omnibus Budget
Reconciliation ACT (COBRA)?
A) COBRA beneficiaries generally are eligible for group coverage during a
maximum of 48 months for qualifying events
B) COBRA coverage begins on the date that healthcare coverage would otherwise
have been lost because of a qualifying event
C) COBRA establishes specific criteria for plans, qualified beneficiaries, and
qualifying events to be eligible for benefits
D) Group health coverage for COBRA participants is usually more expensive than
health coverage for active employee - CORRECT ANSWERS - A) COBRA
beneficiaries generally are eligible for group coverage during a maximum of 48
months for qualifying events
Which of the following is a managed care trend that can reduce utilization and
costs because patients pay higher out-of-pockeet amounts?
A) Requirements for participation in Medicare managed care plans
B) Growth in high-deductible health plans with a Health Savings (HSA) option
C) Growth in participation in Medicaid managed care plans
EXAM QUESTIONS AND ANSWERS (VERIFIED AND WELL DETAILED
ANSWERS) LATEST 2025/2026
The No Surprise Act was a product of:
A) The Health Insurance Portability Act
B) The Consolidation Appropriations Act
C) The Treaty of Algeron
D) The Affordable Care Act - CORRECT ANSWERS - D) The Affordable Care
Act
Which of the following is an advantage of direct contracting?
A) Providers do not have to adjudicate claims for payment
B) Employers can save the cost of working with an insurance company
C) It allows the patients to have a choice of providers and physicians
D) Providers can work directly with employers to reduce the cost of providing
insurance - CORRECT ANSWERS - D) Providers can work directly with
employers to reduce the cost of providing insurance
Accountable Care Organizations (ACOs) have all of the following characteristics
EXCEPT:
,A) Patient centric care model
B) Financial incentive for quantity of care
C) Integrated care coordination
D) Electronic Medical Record System - CORRECT ANSWERS - B) Financial
incentive for quantity of care
The Emergency Treatment and Active Labor Act (EMTALA) governs when a
patient may be transferred from one hospital to another when in a(n) condition:
A) Life threatening
B) Non-emergency
C) Stable
D) Chronic - CORRECT ANSWERS - A) Life threatening
STAR ratings are used to indicate the quality of:
A) Accountable Care Organizations performance
B) Medicare Advantage health plan performance
C) Services provided by hospitals
D) Services provided by physicians - CORRECT ANSWERS - B) Medicare
Advantage health plan performance
To evaluate an organization's compliance with the CMS COP standards and other
accreditation requirements, is the purpose of:
,A) A comprehensive accreditation process
B) Recovery Audits
C) The American Osteopathic Association
D) A clean claim - CORRECT ANSWERS - A) A comprehensive accreditation
process
What is tiering?
A) Typically fixed dollar amounts paid by the insured directly to the practitioner
per episode of care
B) Healthcare coverage products featuring narrow networks, high cost sharing and
very low premiums
C) An effort by insurers to increase premiums and to address calls from employers
and the public for improved quality
D) The ranking or classifying of one or more of the provider delivery system
components to influence choice - CORRECT ANSWERS - D) The ranking or
classifying of one or more of the provider delivery system components to influence
choice
Which piece of information is NOT necessary for claims processing?
A) Provider or referring provider identification
B) Family medical history
, C) Type of service
D) Procedure code - CORRECT ANSWERS - B) Family medical history
Which option is NOT true concerning the Consolidated Omnibus Budget
Reconciliation ACT (COBRA)?
A) COBRA beneficiaries generally are eligible for group coverage during a
maximum of 48 months for qualifying events
B) COBRA coverage begins on the date that healthcare coverage would otherwise
have been lost because of a qualifying event
C) COBRA establishes specific criteria for plans, qualified beneficiaries, and
qualifying events to be eligible for benefits
D) Group health coverage for COBRA participants is usually more expensive than
health coverage for active employee - CORRECT ANSWERS - A) COBRA
beneficiaries generally are eligible for group coverage during a maximum of 48
months for qualifying events
Which of the following is a managed care trend that can reduce utilization and
costs because patients pay higher out-of-pockeet amounts?
A) Requirements for participation in Medicare managed care plans
B) Growth in high-deductible health plans with a Health Savings (HSA) option
C) Growth in participation in Medicaid managed care plans
