Free CPB Exam Flashcards

The end-to-end financial process from patient scheduling and registration through final payment posting and account closure. CPB scope: eligibility verification, charge capture, coding, claim submission, payment posting, denial work, patient billing, and collections.

A claim submitted with no defects, missing data, or special handling required, allowing the payer to adjudicate without additional information. Clean claims trigger prompt-pay statutes (typically 30 days for electronic Medicare claims, varies by state for commercial).

The standard paper claim form used by physicians and non-institutional providers to bill professional services. Maintained by the National Uniform Claim Committee (NUCC). Box 21 holds ICD-10-CM codes; Box 24D holds CPT/HCPCS codes with modifiers.

Institutional claim form used by hospitals, skilled nursing facilities, home health agencies, and other facilities to bill inpatient and outpatient services. Maintained by the National Uniform Billing Committee (NUBC). Uses revenue codes, condition codes, and value codes.

Both are HIPAA-mandated electronic claim formats. 837P (Professional) is the electronic equivalent of the CMS-1500. 837I (Institutional) is the electronic equivalent of the UB-04. Selecting the wrong format causes immediate clearinghouse rejection.

HIPAA transaction sent by payers to providers explaining claim adjudication results: paid amount, adjustments, denials, and patient responsibility. Posts automatically into practice management systems and replaces paper EOBs/RAs for the provider.

The EOB (Explanation of Benefits) is sent to the patient explaining how a claim was processed. The RA (Remittance Advice, paper or 835 ERA) is sent to the provider with the payment. Neither document is a bill; both detail allowed amounts, payments, and patient responsibility.

HIPAA transactions used to verify insurance coverage before a service. The provider sends a 270 inquiry; the payer returns a 271 response detailing active coverage, copay, deductible status, and benefit limits. Verifying eligibility is the single best front-end denial prevention step.

HIPAA transactions used to check claim status after submission. The 276 is the inquiry; the 277 is the payer response (pending, paid, denied, in process). Used by billers to manage A/R aging and follow up on unpaid claims.

Two-digit code on the CMS-1500 Box 24B identifying where service was rendered (e.g., 11 = Office, 21 = Inpatient Hospital, 22 = On-Campus Outpatient, 23 = Emergency Room, 02/10 = Telehealth). Wrong POS triggers underpayment or denial because facility vs. non-facility rates differ.

Part A covers inpatient hospital, skilled nursing, hospice, and some home health—billed on UB-04/837I. Part B covers physician services, outpatient care, durable medical equipment, and preventive services—billed on CMS-1500/837P. Part C is Medicare Advantage; Part D is prescription drugs.

Provider who has signed an agreement to accept Medicare assignment on all claims. Receives 5% higher fee schedule than non-par, faster payment, and direct reimbursement. Patient is responsible only for deductible and 20% coinsurance after Medicare-approved amount.

Non-participating Medicare providers who do not accept assignment may charge a maximum of 115% of the non-par Medicare fee schedule (which itself is 95% of the par fee schedule). Charging above this limiting charge violates Medicare rules and can trigger penalties.

Written notice given to a Medicare patient before delivering a service Medicare is likely to deny as not medically necessary. The signed ABN allows the provider to bill the patient if Medicare denies. Without a valid ABN, the provider must write off the charge.

Medicare is a federal program for people 65+, certain disabled persons, and ESRD patients. Medicaid is a joint federal-state program for low-income individuals with state-specific eligibility and benefits. Medicaid is always the payer of last resort when other coverage exists.

Federal health program covering active-duty military, retirees, and their families. Plans include TRICARE Prime (HMO-like), Select (PPO-like), and For Life (Medicare wraparound). Providers must verify eligibility through DEERS before billing; civilian providers can bill as network or non-network.

State-regulated insurance covering work-related injuries; rules vary by state. Bills go to the employer's WC carrier, not the patient's health insurance. The patient owes no copay, deductible, or coinsurance for accepted claims, and providers usually accept the state WC fee schedule as payment in full.

Privately purchased or employer-sponsored coverage from carriers such as UnitedHealthcare, Aetna, Cigna, and BCBS plans. Billing rules vary by payer contract; verify in-network status, benefits, prior authorization needs, and timely filing windows before service.

Process determining the order of payment when a patient has two or more plans. The primary pays first to its allowed amount; the secondary considers the remaining balance. Standard rules: employee plan is primary over spouse plan; the birthday rule applies to dependent children.

When a dependent child is covered under both parents' plans, the plan of the parent whose birthday (month and day, not year) falls earliest in the calendar year is primary. If both parents share a birthday, the plan in effect longer is primary. Court orders override this rule.

Federal regulation under 45 CFR Parts 160 and 164 protecting individually identifiable health information (PHI). Limits use and disclosure to treatment, payment, and operations (TPO) without authorization. Requires minimum necessary standard and patient access to records within 30 days.

Sets administrative, physical, and technical safeguards for electronic PHI (ePHI). Requires risk analysis, access controls, audit logs, encryption where reasonable, and workforce training. Applies to covered entities and business associates handling ePHI.

Requires covered entities to notify affected individuals within 60 days of discovering a breach of unsecured PHI. Breaches affecting 500+ individuals must also be reported to HHS and prominent media outlets in the affected state; smaller breaches are reported annually to HHS.

Federal law (31 U.S.C. §§ 3729-3733) prohibiting knowingly submitting false or fraudulent claims to federal payers. Penalties include treble damages plus per-claim civil penalties (currently $13,946-$27,894 adjusted annually). Includes qui tam whistleblower provisions.

Criminal statute (42 U.S.C. § 1320a-7b) prohibiting knowing payment or receipt of remuneration to induce referrals of federal healthcare program business. Requires intent. Violations bring up to 10 years' imprisonment, $100,000 per kickback fines, and exclusion from federal programs.

Civil statute (42 U.S.C. § 1395nn) prohibiting physicians from referring Medicare/Medicaid patients for designated health services to entities with which the physician or family has a financial relationship, unless an exception applies. Strict liability—no intent required.

Emergency Medical Treatment and Labor Act requires Medicare-participating hospitals with emergency departments to provide a medical screening exam and stabilizing treatment regardless of insurance or ability to pay. Billing follow-up cannot delay the screening exam.

Employee Retirement Income Security Act regulates self-funded employer health plans. ERISA plans are exempt from state insurance laws, follow federal appeals procedures, and require providers to obtain a member's assignment of benefits to pursue payment directly.

Established essential health benefits, prohibited pre-existing condition exclusions, allowed dependent coverage to age 26, and required preventive services with no cost-sharing for in-network providers. ACA marketplace plans use the same CMS-1500/837P billing format as commercial plans.

Effective January 1, 2022, the No Surprises Act bars balance billing for out-of-network emergency services, air ambulance, and certain non-emergency services at in-network facilities. Disputes between providers and payers go through Independent Dispute Resolution (IDR).

Federal law governing third-party debt collectors. Prohibits calls before 8 AM or after 9 PM, harassment, false statements, and contact at work if the employer disallows it. Does not apply to a provider collecting its own debt, but most state laws extend similar rules.

Regulates reporting of consumer accounts to credit bureaus. Medical debt under $500 cannot be reported (effective April 2023), paid medical collections must be removed from credit reports, and unpaid medical debt cannot be reported until 365 days past due.

Charity care is forgiveness of patient balances based on documented financial hardship under the provider's financial assistance policy. Bad debt is uncollectible amounts written off after collection efforts fail. 501(r) nonprofit hospitals must have a written Financial Assistance Policy.

Bill sent to the patient showing the balance owed after insurance adjudication, including services, allowed amounts, insurance payments, adjustments, and remaining patient responsibility. Best practice: send within 30 days of insurance payment to maintain a tight collection cycle.

Deductible: fixed annual amount the patient pays before insurance pays. Copay: flat per-visit dollar amount (e.g., $30). Coinsurance: percentage of the allowed amount after deductible (e.g., 20%). All count toward the out-of-pocket maximum, after which insurance pays 100% of covered services.

The maximum the payer will recognize for a service under the provider's contract. The difference between billed and allowed is a contractual write-off (CARC code OA-45 or CO-45) the provider cannot bill to the patient if participating with that payer.

The Medicare physician payment methodology. Payment = (Work RVU + Practice Expense RVU + Malpractice RVU) x Geographic Practice Cost Index x Conversion Factor. Used to build the Medicare Physician Fee Schedule (MPFS) for CMS-1500/837P services.

Inpatient prospective payment classification grouping hospital stays by diagnosis, procedures, and complications. Each MS-DRG has a relative weight; payment = weight x hospital base rate. Pays a fixed amount per admission regardless of length of stay, encouraging efficient care.

Outpatient prospective payment classification used under Medicare's OPPS for hospital outpatient services. Bundles related services into payment groups based on HCPCS codes and clinical similarity. Multiple APCs can be paid per claim, unlike single-DRG inpatient payment.

CMS-published edits preventing improper unbundling and mutually exclusive code pairs. Procedure-to-Procedure (PTP) edits flag codes that cannot be billed together; Medically Unlikely Edits (MUEs) cap units per line. Some pairs allow override with an appropriate modifier.

A maximum units-of-service value for a HCPCS/CPT code on a single date of service for the same beneficiary. Units exceeding the MUE are denied. MUEs prevent obvious billing errors such as billing 50 units of a unilateral procedure.

Billing component CPT codes separately when a comprehensive bundled code exists. Considered fraudulent under the False Claims Act when intentional. NCCI Procedure-to-Procedure edits catch most unbundling attempts; the bundled code is paid and the component code is denied.

Significant, Separately Identifiable Evaluation and Management Service on the same day as another procedure. Appended to the E/M code (not the procedure). Heavy audit target—documentation must clearly support a separate, distinct E/M beyond the procedure's inherent assessment.

Distinct Procedural Service used to override NCCI edits when two services that are normally bundled were performed at different anatomic sites, different sessions, or different encounters. CMS prefers more specific X{EPSU} modifiers (XE, XP, XS, XU) when applicable.

Modifier 26 = professional component only (physician's interpretation). Modifier TC = technical component only (equipment, supplies, technician). A global service (no modifier) covers both. Billing both 26 and TC for the same service on the same day duplicates a global charge.

Deadline from date of service for submitting a claim. Medicare allows 12 months (one calendar year). Medicaid varies by state (often 90-365 days). Commercial payers commonly require 90-180 days. Claims filed late are denied with no appeal rights in most contracts.

Claim Adjustment Reason Codes (CARCs) explain why a payment differs from billed amount (e.g., CO-45 = contractual). Remittance Advice Remark Codes (RARCs) provide supplemental detail (e.g., N130 = consult plan benefits). Billers use both to determine whether to appeal, bill the patient, or write off.

On a remittance, the group code shows financial responsibility. CO = Contractual Obligation (provider write-off). PR = Patient Responsibility (bill the patient). OA = Other Adjustment. PI = Payer Initiated Reduction. Misreading group codes is the most common cause of incorrect patient billing.

A corrected claim (frequency code 7 on 837P, or resubmission with proper indicator) fixes data errors on the original claim. An appeal challenges a payer's adjudication decision and requires medical records or written justification. Sending an appeal as a corrected claim restarts timely filing and loses appeal rights.

Five levels: (1) Redetermination by the MAC within 120 days, (2) Reconsideration by a Qualified Independent Contractor, (3) Administrative Law Judge hearing (requires minimum amount in controversy), (4) Medicare Appeals Council review, (5) Federal District Court. Each level has its own filing deadline.