Certified Specialist Payment Rep
(HFMA) Exam (Latest Update 2025 /
2026) Questions & Answers | Grade
A | 100% Correct (Verified Solutions)
Question:
The three technique application methods used for utilization management
include the following:
Answer:
-Prospective UM Techniques - UM reviews the need for inpatient care or
other care before admission. The health plan determines, at this point,
whether it will pay for the service
-Concurrent UM Techniques - Authorization required during a patient's
inpatient admission
-Retrospective UM Techniques - Authorization reviews to determine medical
necessity of a service, treatment or procedure
,Question:
Catastrophic Case Management
Answer:
used to manage diseases associated with very high costs of care.
Question:
PCMH model
Answer:
a term used to describe a model of care in which primary care services are
delivered to families in an accessible, continuous, comprehensive, and
integrated fashion.
Question:
Electronic Data Interchange (EDI)
Answer:
the exchange of computerized data in a standardized format allows both
healthcare providers and payers to exchange common information required to
improve the quality of care while measurably reducing the cost of that care.
,Question:
The specific roles and responsibility of each level within the small physician
practice managed care infrastructure included the following:
Answer:
-Practice Manager - Oversee all operational aspects of the practice, including
managed care contracting.
-Physician Leader(s) - Provide input to the practice manager regarding
expected/target reimbursement rates and help identify any specific aspects of
the contract that may be difficult to administer.
-Registration Staff - Assist with eligibility verification and accurate entry of
patient insurance information into the practice management or billing
system.
-Clinical Staff - Must be familiar with payer requirements for appropriate
documentation of medical necessity and protocols for pre-authorizations.
-Billing Staff - Responsible for submitting claims to the appropriate payers
and managing payments received from payers and patients.
, Question:
Information required for claims processing includes the following:
Answer:
-Patient and/or enrollee identification, DOB, and sex
-Assigned group
-Provider or referring provider identification, as appropriate
-Date of service
-Type of service
-Type of diagnosis/major diagnostic category -Procedure code(s): CPT and
HCPCS codes
-COB information
▪ Primary, secondary, and other diagnosis codes as necessary (as many as five
may be needed under DRGs for hospital reimbursement), including
-DRG classification
-Episode of care identifier
-Revenue center (UB-04) code for hospitalization
(HFMA) Exam (Latest Update 2025 /
2026) Questions & Answers | Grade
A | 100% Correct (Verified Solutions)
Question:
The three technique application methods used for utilization management
include the following:
Answer:
-Prospective UM Techniques - UM reviews the need for inpatient care or
other care before admission. The health plan determines, at this point,
whether it will pay for the service
-Concurrent UM Techniques - Authorization required during a patient's
inpatient admission
-Retrospective UM Techniques - Authorization reviews to determine medical
necessity of a service, treatment or procedure
,Question:
Catastrophic Case Management
Answer:
used to manage diseases associated with very high costs of care.
Question:
PCMH model
Answer:
a term used to describe a model of care in which primary care services are
delivered to families in an accessible, continuous, comprehensive, and
integrated fashion.
Question:
Electronic Data Interchange (EDI)
Answer:
the exchange of computerized data in a standardized format allows both
healthcare providers and payers to exchange common information required to
improve the quality of care while measurably reducing the cost of that care.
,Question:
The specific roles and responsibility of each level within the small physician
practice managed care infrastructure included the following:
Answer:
-Practice Manager - Oversee all operational aspects of the practice, including
managed care contracting.
-Physician Leader(s) - Provide input to the practice manager regarding
expected/target reimbursement rates and help identify any specific aspects of
the contract that may be difficult to administer.
-Registration Staff - Assist with eligibility verification and accurate entry of
patient insurance information into the practice management or billing
system.
-Clinical Staff - Must be familiar with payer requirements for appropriate
documentation of medical necessity and protocols for pre-authorizations.
-Billing Staff - Responsible for submitting claims to the appropriate payers
and managing payments received from payers and patients.
, Question:
Information required for claims processing includes the following:
Answer:
-Patient and/or enrollee identification, DOB, and sex
-Assigned group
-Provider or referring provider identification, as appropriate
-Date of service
-Type of service
-Type of diagnosis/major diagnostic category -Procedure code(s): CPT and
HCPCS codes
-COB information
▪ Primary, secondary, and other diagnosis codes as necessary (as many as five
may be needed under DRGs for hospital reimbursement), including
-DRG classification
-Episode of care identifier
-Revenue center (UB-04) code for hospitalization
