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CSPR - Certified Specialist Payment Rep (HFMA) 2024 Questions & Answers Solved 100% Correct!!
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CSPR - Certified Specialist Payment Rep (HFMA) 2024 Questions & Answers Solved 100% Correct!!
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Name: Score:125 Multiple choice questions
Term 1 of 125
Which of the following terms refers to information about any other health plan or carrier that may
share liability for healthcare expenses via a spouse's coverage or the like?
Birthday rule
Explanation of benefits (eob)
Coordination of benefits (COB)
Remittance advice (ra)
Term 2 of 125
What is tiering?
The assessment of healthcare costs without regard to provider performance.
The ranking or classifying of one or more of the provider delivery system components
The categorization of patients based on their income levels.
The process of eliminating all providers from a healthcare network.
,Term 3 of 125
According to MedPAC, which option is a benefit or undesirable consequence of bundling
payments?
-Reimbursement methodology differences
-Operational policies and procedures
-Site of service differentials
-Market differences affecting outpatient and inpatient volumes
-It allows Medicare to pay a set fee per hospitalization episode.
-It would provide the potential to improve efficiency and quality
-It would lead to underutilization of services
-Reimbursement methodology differences
-Operational policies and procedures
-Market differences affecting outpatient and inpatient volumes
-General payer or provider criteria
-Reimbursement levels and parameters
-Provider costs and responsibilities
Definition 4 of 125
-requires hospitals and Critical Access Hospitals (CAH) to provide notification to individuals
receiving observation services as outpatients for more than 24 hours explaining the status of the
individual as an outpatient, not an inpatient, and the implications of such status.
-Requirements - The MOON must be provided no later than 36 hours after observation services
are initiated or, if sooner, upon release. An oral explanation of the MOON must be provided,
ideally in conjunction with the delivery of the notice, and a signature must be obtained from the
individual, or a person acting on such individual's behalf, to acknowledge receipt. In cases where
such individual or person refuses to sign the MOON, the staff member of the hospital or CAH
providing the notice must sign the notice to certify that notification was presented.
How is Mcare financed?
Medicare Outpatient Observation Notice (MOON)
Which option is a risk involved in per diem payments?
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as:
,Term 5 of 125
Which of the following is required for claims processing?
-Shift from broad-based toward more focused efforts
-Reduction of administrative costs
-Greater physician involvement
-Patient and/or enrollee ID, age, and gender
-Type of diagnosis/major diagnostic category
-Date of service
-Member volumes by product type
-Historical reimbursement levels by product type
-Historical claims payment and/or submission problems
To bring coverage to millions of Americans who could not or would not purchase health
insurance
, Term 6 of 125
Tiered Provider Networks
-All persons age 65 and older
-Individuals with permanent renal (kidney) failure, eligible for dialysis treatment
-Individuals with certain disabilities
-Delivery network tiering is an effort by insurers to rein in costs and to address calls from
employers and the public for improved quality.
-Tiered networks were first introduced after the cost-cutting success of tiered pharmacy
plans and formularies
-Differentiation between existing and new contracts
-Reimbursement levels and parameters
-Administrative cost criteria
Provider costs and responsibilities criteria
-General payer (or provider) criteria
-Criteria Relating to Compatibility with Organization Goals o Volume criteria
-Risk assumption criteria
-Part A - provides inpatient/hospital, hospice, and skilled nursing coverage
-Part B - provides outpatient/medical coverage
-Part C - an alternative way to receive your Medicare benefits (known as Medicare
Advantage)
-Part D - prescription drug coverage
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