Free NHA Revenue Cycle and Health Insurance Claims Questions and Answers — Questions and Answers
Question 1: Which of the following is typically the first step in the healthcare revenue cycle?
- Claims submission
- Patient pre-registration (Correct answer)
- Payment posting
- Denial management
Correct answer: Patient pre-registration
The revenue cycle begins before the patient even sees a provider. Pre-registration involves collecting the patient's demographic and insurance information to verify eligibility and benefits, which is the foundational first step.
Question 2: The CMS-1500 form is used to submit claims for which type of services?
- Inpatient hospital stays
- Skilled nursing facility services
- Physician office visits and procedures (Correct answer)
- Prescription drugs from a pharmacy
Correct answer: Physician office visits and procedures
The CMS-1500 is the standard claim form used by physicians and other non-institutional providers to bill for their professional services. Inpatient hospital services are billed on a different form, the UB-04.
Question 3: A patient's insurance plan requires them to pay $500 out-of-pocket for medical services before the insurance company will begin to pay. This amount is known as the:
- Copayment
- Premium
- Deductible (Correct answer)
- Coinsurance
Correct answer: Deductible
A deductible is a fixed amount that a patient must pay each year before their health insurance benefits begin to cover costs. After the deductible is met, the patient typically pays a copayment or coinsurance for covered services.
Question 4: What is the process of reviewing a claim by an insurance carrier to determine payment or denial called?
- Scrubbing
- Adjudication (Correct answer)
- Pre-authorization
- Appealing
Correct answer: Adjudication
Adjudication is the formal process where the insurance payer reviews a submitted claim against the patient's benefit plan. During this process, the payer checks for eligibility, medical necessity, coding accuracy, and policy compliance before deciding to pay, deny, or reduce the claim.
Question 5: A document sent to a patient from their insurance company that details how a claim was processed is known as a(n):
- Remittance Advice (RA)
- Explanation of Benefits (EOB) (Correct answer)
- CMS-1500 Claim Form
- Advance Beneficiary Notice (ABN)
Correct answer: Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a statement sent to the member (patient) that explains what medical treatments and services were paid for on their behalf. It is not a bill, but it details the amount billed, the amount allowed, what the insurance paid, and the patient's financial responsibility.
Question 6: Which of the following is an example of a government-sponsored health insurance plan?
- Blue Cross Blue Shield
- Aetna
- Cigna
- Medicare (Correct answer)
Correct answer: Medicare
Medicare is a federal health insurance program primarily for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease. Blue Cross Blue Shield, Aetna, and Cigna are all private insurance companies.
Free NHA Revenue Cycle and Health Insurance Claims Questions and Answers
Which of the following is typically the first step in the healthcare revenue cycle?