CPCA CPCA Reimbursement and Payer Policies

Question 1

Which term describes the maximum amount a payer will reimburse for a specific service based on fee schedule data?

Accepted Answer

Allowed amount

Answer

Billed charge

Answer

Deductible

Answer

Copayment

Question 2

A dermatology practice submits a claim and receives a payment that is less than the billed amount with no explanation. What should the biller do first?

Accepted Answer

Request an Explanation of Benefits (EOB)

Answer

Write off the balance

Answer

Bill the patient immediately

Answer

Resubmit the claim with a higher amount

Question 3

Which type of payer plan typically requires patients to select providers from an approved network to receive full benefits?

Accepted Answer

Health Maintenance Organization (HMO)

Answer

Indemnity plan

Answer

Worker's Compensation

Answer

TRICARE

Question 4

What is the term for the process of verifying a patient's insurance coverage and benefits before services are rendered?

Accepted Answer

Eligibility verification

Answer

Authorization

Answer

Credentialing

Answer

Claims adjudication

Question 5

A payer requires prior authorization for a laser skin resurfacing procedure. What happens if the provider performs the service without obtaining it?

Accepted Answer

The claim may be denied entirely

Answer

The claim is automatically paid at 50%

Answer

The provider is penalized by the state board

Answer

The patient's deductible is waived

Question 6

Which Medicare administrative document outlines covered services, billing requirements, and payment rules for specific specialties?

Accepted Answer

Local Coverage Determination (LCD)

Answer

UB-04 form

Answer

ABN form

Answer

CMS-1500