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CRCR FINAL EXAM 600 QUESTIONS & CORRECT
ANSWERS (VERIFIED)
835 Record - CORRECT ANSWER >>> A standard electronic message between a health plan and provider sending remittance data on a claim to the provider. 837 Record - CORRECT ANSWER >>> A standard electronic message between a provider and health plan sending data on a claim to the health plan. AAR - CORRECT ANSWER >>> After-hours activity report ABN - CORRECT ANSWER >>> Advanced Beneficiary Notice ACC - CORRECT ANSWER >>> ambulatory care center Access - CORRECT ANSWER >>> The ability to receive hospital, physician or other medical services without regard to an individuals ability to pay. Accountable Care Organization (ACO) - CORRECT ANSWER >>> A coordinated group of healthcare providers (including physicians, hospitals, and other types of providers) organized to improve quality and lower the cost of care to a defined group of patients. Accounting Identity - CORRECT ANSWER >>> Also known as the accounting equation; assets = liabilities + equity. Accounts Payable - CORRECT ANSWER >>> A current liability where funds are owed to suppliers.
Accounts Payable Distribution - CORRECT ANSWER >>> An account computer system report that details the amounts paid to vendors by date, purchase order, and expense classification. Accounts receivable (A/R) - CORRECT ANSWER >>> Money owed to an organization for goods or services furnished. A/R Collection Period - CORRECT ANSWER >>> Number of days in the accounting period divided by accounts receivable turnover. This ratio tells you the average time it takes to collect amounts due. A/R Turnover - CORRECT ANSWER >>> Services rendered on credit during the period divided by the A/R balance. This ratio tells you how many times you collect your AR in a given cycle. Accounts Receivable Aging - CORRECT ANSWER >>> A report that summarizes accounts receivable from different sources (such as Medicare or commercial insurance) by thirty day increments. Accreditation - CORRECT ANSWER >>> Formal process by which an agency or organization evaluates and recognizes a program as meeting certain predetermined criteria or standards. A formal process for certifying that providers and health plans meet predetermined standards. Accredited Standards Committee X12 (ASC X12) - CORRECT ANSWER >>> A committee of the American National Standards Institute (ANSI) responsible for the development and maintenance of electronic data interchange (EDI) standards for many industries. The ASC 'X12N' is the subcommittee of ASC X12 responsible for the EDI health insurance administrative transactions such as 837 Institutional Health Care Claim and 835 Professional Health Care Claim forms Accrual - CORRECT ANSWER >>> An expense or a revenue that occurs before the business pays or receives cash. An accrual is the opposite of a deferral.
Administrative Load Ratio - CORRECT ANSWER >>> In a health plan, the percentage of total premiums collected expended for administrative costs. Administrative services only (ASO) - CORRECT ANSWER >>> Contract where a third-party administrator or insurer provides administrative services to an employer for a fixed fee per employee. Services usually include claims processing but may also include such services as group billing, actuarial analysis, utilization review, and provider network development. admission - CORRECT ANSWER >>> Formal registration of a patient who is to be provided with medical care by the provider. Admitting diagnosis - CORRECT ANSWER >>> The patient's condition determined by a physician at admission to an inpatient facility for admission and coded according to current diagnosis coding conventions. ADP - CORRECT ANSWER >>> Automated Data Processing ADR - CORRECT ANSWER >>> Average Daily Revenue ADRG - CORRECT ANSWER >>> Adjacent diagnosis-related group; alternative diagnosis related group. ADS - CORRECT ANSWER >>> Alternative delivery system ADSC - CORRECT ANSWER >>> Average Daily Service Charge ADT - CORRECT ANSWER >>> admission, discharge, transfer
Advance Beneficiary Notice (ABN) - CORRECT ANSWER >>> Document that acknowledges patient responsibility for payment if Medicare denies the claim. Advanced Practice Provider (APP) - CORRECT ANSWER >>> Clinical nurse specialists (CNS), nurse practitioners (NPs) and Physician Assistants (PAs). AFDC - CORRECT ANSWER >>> Aid to Families with Dependent Children AFDS - CORRECT ANSWER >>> Alternative financing and delivery systems Affiliation - CORRECT ANSWER >>> Arrangement between organizations by which the named organizations remain independent but have influence on each other; affiliations may or may not be permanent and my not result in common ownership or control of the affiliates. After care - CORRECT ANSWER >>> Services following hospitalization or rehabilitation. Aging - CORRECT ANSWER >>> Process wherein accounts receivable or accounts payable are scheduled, listed or arranged based on elapsed time from date of service or transaction. AHA - CORRECT ANSWER >>> American Hospital Association AHP - CORRECT ANSWER >>> allied health professional AHRQ - CORRECT ANSWER >>> Agency for Healthcare Research and Quality Aid to Families with Dependent Children (AFDC) - CORRECT ANSWER >>> Federal funds for children in families that fall below state standards of need. In 1996, Congress abolished AFDC, the largest federal cash transfer program, and replaced it with the Temporary Assistance for Needy Families (TANF) block grant
outpatient visits/services what DRGs are to inpatient hospital admissions; the payments are based on categories or groupings of like or similar services requiring like or similar professional services and supply utilization. Ambulatory Payment Classification (APC) - CORRECT ANSWER >>> Prospective payment system used to calculate reimbursement for outpatient care according to similar clinical characteristics and in terms of resources required. Ambulatory setting - CORRECT ANSWER >>> A type of health care setting where health servies are provided on an outpatinet basis. Ambulatory setting usually include physician's offices, clinics, and surgery centers AMCC - CORRECT ANSWER >>> Automated multi-channel chemistry American National Standards Institute (ANSI) - CORRECT ANSWER >>> Parent organization of the ASC X12 and the recognized coordinator and clearinghouse for information on United States and Canadian national standards. Ancillary Services - CORRECT ANSWER >>> Supportive services other than routine hospital services provided by the facility, such as x-ray films and laboratory tests. Anniversary - CORRECT ANSWER >>> The beginning of a subscriber group's benefit year. ANSI - CORRECT ANSWER >>> American National Standards Institute APC - CORRECT ANSWER >>> Ambulatory Payment Classification APG - CORRECT ANSWER >>> Ambulatory patient group
APHP - CORRECT ANSWER >>> Acute partial hospitalization program APP - CORRECT ANSWER >>> Advanced Practice Provider Appeal - CORRECT ANSWER >>> Request by a provider or beneficiary to have coverage and/or payment determination reconsidered. AR - CORRECT ANSWER >>> accounts receivable AS - CORRECT ANSWER >>> Admission scheduling ASC - CORRECT ANSWER >>> Administrative services contract; ambulatory surgical/surgery center ASF - CORRECT ANSWER >>> Ambulatory surgical facility ASO - CORRECT ANSWER >>> Administrative Services Only Asset - CORRECT ANSWER >>> Anything of value that is owned Assignment - CORRECT ANSWER >>> Agreement in which a patient transfers to a provider the right to receive payment from a third party for the service the patient has received. Attending physician - CORRECT ANSWER >>> Medical staff member who is legally responsible for the care and treatment given to a patient. Attestation - CORRECT ANSWER >>> Physician's report attesting to the principal diagnosis, secondary diagnosis, and names of the major procedures performed, which must be completed
Balance Sheet - CORRECT ANSWER >>> A financial statement that reports assets, liabilities, and owner's equity on a specific date. Statement that lists the financial resources (assets), financial obligations (liabilities), and ownership rights (equity/fund balance) within the organization. Balanced Budget Act of 1997 (BBA) - CORRECT ANSWER >>> Federal legislation, passed by Congress and signed by President Clinton, that cut health care expenditures for Medicare and other government-sponsored programs to achieve a balanced budget Bankruptcy - CORRECT ANSWER >>> Federal system of marshaling the assets of a financially distressed person or organization and paying the creditors' on a pro rata basis. Batch control tasks - CORRECT ANSWER >>> Figures that ensure batch processing has been performed correctly by comparing output to the input totals, record or document counts, or cash totals. batch processing - CORRECT ANSWER >>> Accumulating transaction records into groups or batches for processing at a regular interval such as daily or weekly. The records are usually sorted into some sequence (such as numerically or alphabetically) before processing. BBA - CORRECT ANSWER >>> Balanced Budget Act of 1997 behavioral health - CORRECT ANSWER >>> Healthcare services, such as those provided by a psychiatrist, psychologist, social worker, hospital, or other facility duly licensed and qualified to treat mental health and chemical dependency conditions. Benchmarking - CORRECT ANSWER >>> Process of identifying industry standards and best practices. Benchmarks - CORRECT ANSWER >>> Industry standards for specific tasks or performance normally set by surveying groups and comparing data across groups.
Beneficiary - CORRECT ANSWER >>> A person on behalf of which an insurance plan payment is made to a healthcare provider. Benefit days - CORRECT ANSWER >>> Days that a patient is eligible for covered services. benefit package - CORRECT ANSWER >>> The set of services, such as physician visits, hospitalizations, prescription drugs, that are covered by an insurance policy or health plan. The benefit package will specify any cost-sharing requirements for services, limits on particular services, and annual or lifetime spending limits. Benefit payment - CORRECT ANSWER >>> A payment by an insurer based on the terms of an insurance policy on behalf of a plan beneficiary or member. Benefit year - CORRECT ANSWER >>> the 12-month period for which health insurance benefits are calculated, not necessarily coinciding with the calendar year. Health insurance companies may update plan benefits and rates at the beginning of the benefit year. Billed charges - CORRECT ANSWER >>> The amount the provider bills to the payer for a specific item or service such as a visit to a physician or an inpatient day at a healthcare facility; gross prices charged for healthcare services. Same as submitted charges Billing - CORRECT ANSWER >>> Submission of a claim for payment for services rendered by a healthcare provider to the insured or to the patient. Billing and collection function - CORRECT ANSWER >>> Also known as patient financial services or PFS, the function in a healthcare provider entity that compiles and submits claims to insurers or patients and collects amounts due for services.
Bylaws - CORRECT ANSWER >>> Organizational document for for-profit and not-for-profit organizations that supplements the articles of incorporation, establishes procedural rules not found in the articles of incorporation or enabling statute, and is not a public document. C and E - CORRECT ANSWER >>> Consultation and examination CAH - CORRECT ANSWER >>> Critical Access Hospital Calculation for adjusted discharge - CORRECT ANSWER >>> For adjusted discharges or patient days; adjusted discharges (days) = inpatient discharges (days) x (1 = [gross outpatient revenue/gross inpatient revenue]) capital assets - CORRECT ANSWER >>> Assets of a permanent nature used in the production of income, such as land, buildings, machinery, and equipment; usually distinguishable under income tax law from "inventory," assets held for sale to customers in the ordinary course of the taxpayer's trade or business capital budget - CORRECT ANSWER >>> A budget that describes the expected capital acquisitions (equipment, buildings) for a business during a specific period of time. capital lease - CORRECT ANSWER >>> A contractual agreement allowing one party (the lessee) to use another party's asset (the lessor); accounted for like a debt-financed purchase by the lessee. A lease with or without the eventual opportunity to purchase the asset. Capital Structure Ratios - CORRECT ANSWER >>> Financial rations that evaluate the mix of debt and equity in a business. Capitation - CORRECT ANSWER >>> System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a
stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan. Care purchaser - CORRECT ANSWER >>> Individual or entity that contributes to the purchase of healthcare services Carrier - CORRECT ANSWER >>> Insurer of a group contract that agrees to underwrite (accept the risk) and to provide certain types of insurance coverage. Carve Out - CORRECT ANSWER >>> Set of health plan benefits that are contracted separately from the standard benefits package case management - CORRECT ANSWER >>> Method of managing the provision of healthcare with the goal of improving continuity and quality of care while lowering cost. Case Manager - CORRECT ANSWER >>> Clinical professional who works with patients, providers, families, and insurers to coordinate all the services deemed necessary to care for the patient in the best and lowest cost medically appropriate setting. Case Mix Index - CORRECT ANSWER >>> The average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity (acuity) of a specific group in relation to the other groups in the classification system Case Rate - CORRECT ANSWER >>> Payment to a provider for all care for a specific service, such as a surgery or treatment of an illness. Cash - CORRECT ANSWER >>> Also called currency. It is used to determine liquidity ratios and transact financial business. Cash is considered the most liquid of all assets.
CELIP - CORRECT ANSWER >>> Claims Expansion and Line Item Processing. Medicare's expanded claim form necessary to perform medical reviews and capture savings at the line item level under the outpatient PPS system. Census - CORRECT ANSWER >>> Count of patients who at the time counted were duly registered in a provider's care, normally on an inpatient basis; Count of all people in the United States taken every ten years by the federal government; Listing of all eligible members who are to be covered by a plan. Centers for Medicare and Medicaid Services (CMS) - CORRECT ANSWER >>> a federal agency within the U.S. Department of Health and Human Services that is responsible for Medicare and Medicaid, among many other responsibilities. certificate - CORRECT ANSWER >>> Document or benefits booklet issued to a covered individual and a group health insurance plan setting forth the benefits and requirements of that plan Certificate of Medical Necessity (CMN) - CORRECT ANSWER >>> Signed physician attestation document stating services provided under a specific course of treatment are medically necessary. CHAMPUS - CORRECT ANSWER >>> Civilian Health and Medical Program of the Uniformed Services. The Department of Defense administers this program, which pays for healthcare delivered by civilian health providers to retired members and dependents of active members for all military services in the U.S. CHAMPVA - CORRECT ANSWER >>> Civilian Health and Medical Program of the Veterans Administration Change in Net Assets - CORRECT ANSWER >>> The amount of change in Net Assets recorded as a result of earnings during an accounting period. See also Net income
Channeling - CORRECT ANSWER >>> Procedure used in managed care or point-of-service plans as a means of steering or encouraging patients to a specific network of providers through the use of incentives. Patients who use a network provider may be responsible for a lower copayment and/or receive higher insurance benefits then if accessing an out-of-network provider. Charge - CORRECT ANSWER >>> The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid. charge-based reimbursement - CORRECT ANSWER >>> Payment to health care provider based on billed charges and not on a prospectively negotiated amount. Charge capture - CORRECT ANSWER >>> The process of recording a charge for a service or item on a patient's account. Chargemaster - CORRECT ANSWER >>> A listing of all items for which revenue can be generated in a healthcare provider organization; also referred to as the CDM or charge description master.
