CPMA STUDY GUIDE REVIEW SHEET
SOLVED PROBLEMS FULL SOLUTION
ALREADY PASSED GUARANTEED TO PASS
⩥ FFS.
Answer: Fee-For-Service
⩥ Prepayment Review.
Answer: Review of claims prior to payment. Prepayment
reviews result in an initial determination.
⩥ Postpayment Review.
Answer: Review of claims after payment. May result in either
no change to the initial determination or a revised determination,
indicating an underpayment or overpayment.
⩥ Underpayment.
Answer: A payment a provider receives under the amount due
for services furnished under the Medicare statute and
regulations.
,⩥ Overpayment.
Answer: A payment a provider receives over the amount due for
services furnished under Medicare statutes and regulations
⩥ 5 Common reasons for overpayment are:.
Answer: *Billing for excessive and subsequent payment of the
same service or claim.
*Duplicate submission and payment for same service or claim
*Payment for excluded or Medically unnecessary services.
*Payment for services in setting not appropriate to pt's needs or
condition
*Payment to an incorrect payee.
⩥ MACs.
Answer: Medicare Administrative Contractors
⩥ MAC Responsibilities.
Answer: Process claims from physicians, hospitals, and other
health care professionals, and submit payment to those providers
according to Medicare rules and regulations (including
identifying under- and overpayments).
,⩥ ZPICs.
Answer: Zone Program Integrity Contractors
⩥ PSCs.
Answer: Program Safeguard Contractor
⩥ ZPICs/PSCs.
Answer: Perform investigations that are unique and tailored to
specific circumstances and occur only in situations where there
is potential fraud, and take appropriate corrective actions
⩥ SMRC.
Answer: Supplemental Medical Review Contractor
⩥ SMRC Responsibilities.
Answer: Conduct nationwide medical review as directed by
CMS (includes identifying underpayments and overpayments
⩥ Medicare FFS Recovery Auditors.
, Answer: Review claims to identify potential underpayments and
overpayments in Medicare FFS, as part of the Recovery Audit
Program
⩥ Zone 6.
Answer: All PSCs transitioned to ZPICs with the exception of
Zone 6
⩥ While all contractors focus on a specific area,.
Answer: Each contractor conducting a claim review must apply
all Medicare policies to the claim under review. Additionally,
once a claim is reviewed, a different contractor should not
reopen it. Therefore, it is important when conducting claim
reviews, contractors review each claim in its entirety.
⩥ Claim Review Programs.
Answer: There are 5 claim review programs
⩥ NCCI Edits.
Answer: National Correct Coding Initiative Editor
⩥ NCCI Edits are performed by.
SOLVED PROBLEMS FULL SOLUTION
ALREADY PASSED GUARANTEED TO PASS
⩥ FFS.
Answer: Fee-For-Service
⩥ Prepayment Review.
Answer: Review of claims prior to payment. Prepayment
reviews result in an initial determination.
⩥ Postpayment Review.
Answer: Review of claims after payment. May result in either
no change to the initial determination or a revised determination,
indicating an underpayment or overpayment.
⩥ Underpayment.
Answer: A payment a provider receives under the amount due
for services furnished under the Medicare statute and
regulations.
,⩥ Overpayment.
Answer: A payment a provider receives over the amount due for
services furnished under Medicare statutes and regulations
⩥ 5 Common reasons for overpayment are:.
Answer: *Billing for excessive and subsequent payment of the
same service or claim.
*Duplicate submission and payment for same service or claim
*Payment for excluded or Medically unnecessary services.
*Payment for services in setting not appropriate to pt's needs or
condition
*Payment to an incorrect payee.
⩥ MACs.
Answer: Medicare Administrative Contractors
⩥ MAC Responsibilities.
Answer: Process claims from physicians, hospitals, and other
health care professionals, and submit payment to those providers
according to Medicare rules and regulations (including
identifying under- and overpayments).
,⩥ ZPICs.
Answer: Zone Program Integrity Contractors
⩥ PSCs.
Answer: Program Safeguard Contractor
⩥ ZPICs/PSCs.
Answer: Perform investigations that are unique and tailored to
specific circumstances and occur only in situations where there
is potential fraud, and take appropriate corrective actions
⩥ SMRC.
Answer: Supplemental Medical Review Contractor
⩥ SMRC Responsibilities.
Answer: Conduct nationwide medical review as directed by
CMS (includes identifying underpayments and overpayments
⩥ Medicare FFS Recovery Auditors.
, Answer: Review claims to identify potential underpayments and
overpayments in Medicare FFS, as part of the Recovery Audit
Program
⩥ Zone 6.
Answer: All PSCs transitioned to ZPICs with the exception of
Zone 6
⩥ While all contractors focus on a specific area,.
Answer: Each contractor conducting a claim review must apply
all Medicare policies to the claim under review. Additionally,
once a claim is reviewed, a different contractor should not
reopen it. Therefore, it is important when conducting claim
reviews, contractors review each claim in its entirety.
⩥ Claim Review Programs.
Answer: There are 5 claim review programs
⩥ NCCI Edits.
Answer: National Correct Coding Initiative Editor
⩥ NCCI Edits are performed by.
