Patient Access Foundations
25%of exam
Pre-arrival
21%of exam
SchedulingPre-registrationPayer TypesEligibility & AuthFinancial Clearance
Customer Experience
19%of exam
Customer AssessmentCommunicationAIDETService RecoverySatisfaction Metrics
Arrival
19%of exam
Check-inForms & ConsentsOrder ValidationPatient TrackingWayfinding
Revenue Cycle
16%of exam
Quick Facts
- Exam
- CHAA
- Body
- NAHAM
- Time
- 2 hours
- Questions
- 115 multiple-choice
- Domains
- 5 weighted domains
- Format
- Scenario-based single answer
- Renewal
- Every 2 years
- Blueprint
- Dec 2023 job-task analysis
Two Identifiers Rule
Name plus date of birth, never room number
Full legal name requiredDate of birth requiredMRN backup if neededRoom number never acceptable
ABN vs GFE
ABN
- Original Medicare only
- Medical necessity risk
- CMS-R-131 form
GFE
- Uninsured self-pay patients
- No Surprises Act
- Cost transparency estimate
Coverage risk vs cost estimate
EMTALA Screening Sequence
- Patient requests emergency care→Provide MSE(Regardless of insurance)
- Emergency condition confirmed→Stabilize before transfer
- Facility lacks capability→Certify benefits outweigh risks
- Transfer benefits outweigh risks→Receiving hospital must accept(Confirm capacity first)
- Financial questions arise→Never before the MSE
- Registration desired in parallel→Run alongside screening
Core Compliance Laws
- EMTALA
- 1986 ED screening law
- MSE
- Required medical screening exam
- HIPAA
- 1996 PHI privacy law
- Minimum necessary
- Limit PHI to purpose
- TPO
- Treatment payment operations exempt
- PSDA
- Mandates advance directive disclosure
- False Claims Act
- Bars knowing false billing
- Anti-Kickback Statute
- Bars referral payment inducements
Notice-to-Situation Map
ABN Medicare, GFE self-pay, MOON observation status
ABN: Part B necessity riskGFE: uninsured cost estimateMOON: outpatient observation noticeIMM: inpatient discharge rights
Duplicate Record vs Overlay
Duplicate
- One patient two MRNs
- History split apart
- Fixed by HIM merge
Overlay
- Two patients one MRN
- Data contaminated together
- More dangerous error
Split identity vs merged identity
Which CMS Notice to Issue
- Part B may deny necessity→Issue ABN(Before service)
- Uninsured or self-pay scheduled→Issue GFE(No Surprises Act)
- Medicare inpatient at admission→Issue IMM(Discharge rights)
- Outpatient placed in observation→Issue MOON(Within 36 hours)
- Always-excluded Original Medicare service→Voluntary NEMB(No coverage decision existed)
CMS Patient Notices
- ABN
- Medicare Part B denial warningCMS-R-131
- IMM
- Inpatient discharge rights notice
- MOON
- Observation status outpatient notice
- NEMB
- Voluntary always-excluded service notice
- GFE
- No Surprises Act cost estimate
- Condition Code 44
- Pre-discharge status correction
- MSP questionnaire
- Screens for other coverage
Patient ID & Safety
- Two identifiers
- Full name plus birth date
- NPSG.01.01.01
- Joint Commission ID safety goal
- EMPI
- Enterprise-wide identity index
- MRN
- Single-facility chart number
- Duplicate record
- One patient two MRNs
- Overlay
- Two patients one MRN
- Doe protocol
- Unidentified patient temporary ID
Accreditation & Government Payers
- Joint Commission
- Unannounced periodic surveys
- DNV Healthcare
- ISO 9001 annual surveys
- Deeming authority
- CMS accepts accreditor survey
- Medicare
- Federal 65+ or disability
- Medicaid
- Federal-state low-income program
- TRICARE
- DoD military family coverage
- VA benefits
- Veterans Affairs health coverage
Referral vs Prior Authorization
Referral
- PCP directive
- Gatekeeper plan types
- Sends to specialist
Prior authorization
- Payer approval
- Independent of referral
- Required before service
Who sends vs who approves
Medicare Parts & Plan Types
- Part A
- Inpatient hospital hospice SNF
- Part B
- Outpatient physician DME
- Part C
- Medicare Advantage private plan
- Part D
- Prescription drug coverage
- Original Medicare
- Parts A and B only
- HMO
- PCP referral network required
- PPO
- No referral in-and-out network
- EPO
- No referral no out-network
- POS plan
- Referral plus some out-network
- Self-pay
- No third-party payer
Medicare Advantage vs Original Medicare
Medicare Advantage
- Private commercial-style plan
- Network rules apply
- Often needs prior auth
Original Medicare
- Parts A and B
- CMS-administered nationwide
- Standardized fee schedule
Commercial-style vs standardized rules
Eligibility & Authorization
- 270/271
- Electronic eligibility inquiry response
- Copay
- Fixed dollar amount per visit
- Deductible
- Owed before plan pays
- Coinsurance
- Percent owed after deductible
- OOP maximum
- Annual cost-share cap
- Referral
- PCP directs to specialist
- Prior authorization
- Payer approval before service
- Medical necessity
- Clinical justification for payment
- In-network
- Contracted lower-cost provider
- Retro-authorization
- Rarely available after service
Scheduling & Financial Clearance
- Pre-registration
- Demographics collected before arrival
- Guarantor
- Person responsible for payment
- Subscriber
- Policyholder whose ID applies
- GFE window
- Scales with scheduling lead time
- Financial counseling
- Connects patient to assistance
- Charity care
- Free or reduced-cost care
- PPDR
- Dispute process for GFE overages
AIDET Sequence
Acknowledge, Introduce, Duration, Explanation, Thank you
Acknowledge: greet by nameIntroduce: state your roleDuration: give time estimateExplanation: describe next stepsThank you: close warmly
HCAHPS vs Press Ganey
HCAHPS
- Federal CMS/AHRQ survey
- Publicly reported
- Tied to payment
Press Ganey
- Private vendor
- Often administers HCAHPS
- Adds internal questions
Federal mandate vs vendor tool
Customer Experience Tools
- AIDET
- Acknowledge Introduce Duration Explain Thank
- Service recovery
- Acknowledge apologize correct restore
- Health literacy
- Patient ability to understand
- Interpreter services
- Required for language access
- HCAHPS
- Federal CMS/AHRQ experience survey
- Press Ganey
- Private vendor survey administrator
- PDSA cycle
- Plan Do Study Act
Inpatient vs Observation
Inpatient
- Formal admission order
- Expected 2-plus midnights
- Part A billing
Observation
- Outpatient status
- Monitor before decision
- Part B billing
Admission order vs monitoring status
Arrival & Registration Workflow
- Patient class
- Inpatient outpatient or observation
- Inpatient
- Formally admitted overnight status
- Observation
- Outpatient status pending decision
- General consent
- Covers routine non-invasive care
- Informed consent
- Clinician-obtained procedure-specific consent
- Assignment of benefits
- Payer pays facility directly
- Order validation
- Match order to patient
- Wayfinding
- Helping patients navigate facility
MSP Secondary Triggers
Working aged, disabled, work injury, auto, ESRD
65+ with employer planDisabled with large groupWorkers comp for injuryNo-fault for auto accidentESRD 30-month coordination period
UB-04 vs CMS-1500
UB-04
- Institutional facility claim
- Revenue codes used
- 837I electronic form
CMS-1500
- Professional physician claim
- CPT/HCPCS codes used
- 837P electronic form
Facility bill vs provider bill
COB: Which Plan Pays First
- Dependent two parent plans→Birthday rule(Earlier birth month wins)
- Same birthday both parents→Longer-covered plan(Coverage duration wins)
- Active employee vs dependent→Non-dependent plan primary
- Working-aged 65+, employer 20+→Employer plan primary(Medicare secondary)
- Disabled under 65 large group→Group plan primary(Medicare secondary)
- Work-related injury→Workers comp primary
- Auto accident injury→No-fault liability primary
- First 30 months ESRD→Employer plan primary(Coordination period)
Claim Forms & Codes
- UB-04
- Institutional facility claim form
- CMS-1500
- Professional physician claim form
- 837I
- Electronic institutional claim
- 837P
- Electronic professional claim
- Revenue code
- Identifies hospital department charge
- Occurrence code
- Two-character code plus date
- Condition code
- Flags claim-wide circumstance
- ICD-10-CM
- Diagnosis code why seen
- CPT
- Procedure code what done
- HCPCS Level II
- Supplies equipment drugs codes
Claim Form Pairing
UB-04 for facility, CMS-1500 for physician
UB-04: institutional 837ICMS-1500: professional 837POne visit, two claims
Coordination of Benefits
- COB
- Orders multiple plan payment
- Primary payer
- Pays claim first
- Secondary payer
- Pays remaining covered balance
- Birthday rule
- Earlier birth month wins
- Non-dependent rule
- Subscriber plan beats dependent plan
- MSP
- Medicare pays after certain coverage
- TPL
- Auto or work injury claims
- Medishare
- Not licensed insurance no COB
Collections & Denial Prevention
- POS collection
- Collect liability at visit
- AR aging
- 0-30/31-60/61-90/90-plus buckets
- Clean claim rate
- Claims paid without correction
- Front-end denial
- Registration error root cause
- EMPI search
- Prevents duplicate or overlay
- Counseling referral
- High cost or uninsured trigger
- Verification documentation
- Record date and reference number
Common Traps
Minimum necessary scope
Applies to disclosures ≠ Not for treatment sharing
HIPAA signature myth
Good-faith effort required ≠ Not mandatory to proceed
Condition Code 44 timing
Only before discharge ≠ After discharge needs rebilling
Room number as identifier
Never an identifier ≠ Beds change constantly
Retro-authorization myth
Rarely available after service ≠ Must obtain before service
General vs informed consent
General covers routine care ≠ Informed is clinician-obtained
Birthday rule basis
Month and day only ≠ Birth year is ignored
EMTALA payment timing
Screening comes first ≠ Payment discussion comes after
Last Minute
- 1.115 questions, 2-hour limit.
- 2.Weights: 25 / 21 / 19 / 19 / 16
- 3.EMTALA: screen before payment ever.
- 4.ID = name + DOB, never room.
- 5.ABN = Medicare Part B only.
- 6.GFE = No Surprises Act estimate.
- 7.MSP questionnaire: every Medicare encounter.
- 8.Birthday rule = earlier month wins.
- 9.Prior auth: obtain before service.
- 10.UB-04 = facility; CMS-1500 = physician.
- 11.Condition Code 44: only pre-discharge.
- 12.HCAHPS = federal; Press Ganey = vendor.
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