CSPR STUDY SHEET 2026 EXAM
QUESTIONS AND ANSWERS EXPERT
VERIFIED
◉Out of Pocket maximum. Answer: The dollar limit set on the total
amount of covered charges that will be paid by the enrolee.
◉Percent of Pay. Answer: A rarely used share of cost structure in
which employees out of pocket costs are fixed as percentages of a
respective employee's salary.
◉tiered provider networks. Answer: health insurance products that
group providers into tiers based on the cost or efficiency of care they
deliver and then steer pts to choose these providers through lower
premiums or cost sharing
◉Capitation. Answer: A fixed payment amount based upon the
number of members assigned to a provider.
◉percent of charges. Answer: A payment methodology where a
claim is paid at a predetermined percentage discount rate.
,◉Per diem payment. Answer: Type of prospective payment method
in which the third-party payer reimburses the provider a fixed rate
for each day a covered member is hospitalized.
◉Case Rate Payment. Answer: Payments represent a fixed price for
specified care by paying an agreed upon rate for a specific healthcare
service.
◉DRGs. Answer: Disease classification system that relates the type
of inpatients a hospital treats (case mix) to the costs incurred by the
hospital
◉Medicare severity diagnosis-related groups. Answer: An expanded
version of the basic DRG concept but have clustered patients into
over 900 descriptions
◉APCs. Answer: Ambulatory Payment Classifications
◉Carve-outs. Answer: Sometimes refer to specific benefits or
services that are administered separately from the rest of the
managed care plan and that may be managed by other third parties.
, ◉Percentage of Charge Payments. Answer: A negotiated percentage
off of billed charges can be applied to any or all the services that the
hospital provides
◉TRICARE Prime. Answer: The basic managed care health plan
offered by TRICARE
◉TRICARE Standard. Answer: The fee-for-service health plan
offered by TRICARE.
◉TRICARE. Answer: military health plan that provides services for
active duty personnel and their families, survivors of military
personnel and retired military personnel and their families
◉RBRVS (Resource Based Relative Value Scale). Answer: national fee
system used to calculate the approved amount for Medicare
payments
◉Components used to determine the total RVU. Answer: Years of
experience, Lowest market price for services, Medicare discounts
◉Capitation provider obligations. Answer: Understand costs of care,
accept risks, develop an appropriate data and system set,
operational/financial, clinical infrastructure, stop loss
QUESTIONS AND ANSWERS EXPERT
VERIFIED
◉Out of Pocket maximum. Answer: The dollar limit set on the total
amount of covered charges that will be paid by the enrolee.
◉Percent of Pay. Answer: A rarely used share of cost structure in
which employees out of pocket costs are fixed as percentages of a
respective employee's salary.
◉tiered provider networks. Answer: health insurance products that
group providers into tiers based on the cost or efficiency of care they
deliver and then steer pts to choose these providers through lower
premiums or cost sharing
◉Capitation. Answer: A fixed payment amount based upon the
number of members assigned to a provider.
◉percent of charges. Answer: A payment methodology where a
claim is paid at a predetermined percentage discount rate.
,◉Per diem payment. Answer: Type of prospective payment method
in which the third-party payer reimburses the provider a fixed rate
for each day a covered member is hospitalized.
◉Case Rate Payment. Answer: Payments represent a fixed price for
specified care by paying an agreed upon rate for a specific healthcare
service.
◉DRGs. Answer: Disease classification system that relates the type
of inpatients a hospital treats (case mix) to the costs incurred by the
hospital
◉Medicare severity diagnosis-related groups. Answer: An expanded
version of the basic DRG concept but have clustered patients into
over 900 descriptions
◉APCs. Answer: Ambulatory Payment Classifications
◉Carve-outs. Answer: Sometimes refer to specific benefits or
services that are administered separately from the rest of the
managed care plan and that may be managed by other third parties.
, ◉Percentage of Charge Payments. Answer: A negotiated percentage
off of billed charges can be applied to any or all the services that the
hospital provides
◉TRICARE Prime. Answer: The basic managed care health plan
offered by TRICARE
◉TRICARE Standard. Answer: The fee-for-service health plan
offered by TRICARE.
◉TRICARE. Answer: military health plan that provides services for
active duty personnel and their families, survivors of military
personnel and retired military personnel and their families
◉RBRVS (Resource Based Relative Value Scale). Answer: national fee
system used to calculate the approved amount for Medicare
payments
◉Components used to determine the total RVU. Answer: Years of
experience, Lowest market price for services, Medicare discounts
◉Capitation provider obligations. Answer: Understand costs of care,
accept risks, develop an appropriate data and system set,
operational/financial, clinical infrastructure, stop loss
