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CHAA practice questions

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Question 1Patient Access Operations and Front-End Revenue Cycle

Which combination of identifiers is acceptable for verifying a patient's identity at registration?

  1. Full name and date of birth Correct answer.
  2. Attending physician name and nursing unit
  3. Insurance member ID and group number
  4. Room number and bed assignment

Explanation

Standard patient-safety practice requires two identifiers, and neither may be the patient's location or a clinician's name. Name plus date of birth satisfies that standard. Financial identifiers such as a member ID do not confirm who the person is, because a card can be presented by anyone.

Question 2Patient Access Operations and Front-End Revenue Cycle

A 68-year-old patient has Medicare and is also covered by her current employer's group health plan, which has 25 employees. Which payer is primary for her care?

  1. The employer group health plan Correct answer.
  2. Medicare, because the patient is over 65
  3. The patient's Medigap supplemental policy
  4. Medicaid, as the payer of last resort

Explanation

Under Medicare Secondary Payer working-aged rules, a group health plan of an employer with 20 or more employees pays first for a beneficiary who is still working and covered by that plan. Medicare then considers payment only after the plan has processed the claim. Medigap and Medicaid never move ahead of that primary plan.

Question 3Patient Access Operations and Front-End Revenue Cycle

Which patient cost-sharing term describes a fixed dollar amount collected at the time of service?

  1. Deductible
  2. Allowed amount
  3. Copayment Correct answer.
  4. Coinsurance

Explanation

A copayment is a flat dollar amount the plan requires the patient to pay, commonly collected at check-in. Coinsurance is a percentage of the allowed charge rather than a fixed amount, and a deductible is the amount the patient pays before benefits begin. The allowed amount is the negotiated reimbursement, not a patient obligation.

Question 4Patient Access Operations and Front-End Revenue Cycle

A caller identifying himself as a patient's neighbor asks the registration desk whether the patient was seen yesterday. What is the best response?

  1. State that you cannot confirm or deny that the person is a patient Correct answer.
  2. Say the patient was seen but give no diagnosis
  3. Confirm that the patient had an appointment time yesterday but share no clinical details
  4. Refer the caller to the patient's physician

Explanation

Even the fact that someone received care is protected health information, so staff must neither confirm nor deny it to a caller without an authorization. Referring the caller to a physician or acknowledging an appointment still discloses protected information. Only an appropriate authorization or legal requirement allows disclosure.

Question 5Patient Access Operations and Front-End Revenue Cycle

Which information is most important to collect when scheduling a new patient's first appointment?

  1. The patient's emergency contact and religious preference
  2. The name of the patient's pharmacy and preferred brand
  3. The patient's marital status and employer address
  4. Reason for the visit and the insurance plan Correct answer.

Explanation

The reason for the visit determines the visit type and the length of time needed, while the insurance plan drives eligibility, referral, and authorization steps that must occur before the visit. Demographic details are collected at registration. Pharmacy and emergency contact data do not affect scheduling or front-end coverage work.

Question 6Patient Access Operations and Front-End Revenue Cycle

Which payer requirement allows a non-emergency service to be reviewed for medical necessity before it is performed?

  1. Eligibility verification
  2. Referral
  3. Prior authorization Correct answer.
  4. Coordination of benefits

Explanation

Prior authorization, also called precertification, is the payer's prospective review of medical necessity for a planned service. A referral is a primary care clinician's direction to a specialist, and eligibility verification confirms whether coverage exists at all. Coordination of benefits determines which of two or more plans pays first.

Question 7Patient Access Operations and Front-End Revenue Cycle

A Medicare beneficiary may be asked to sign which form to acknowledge that a service might not be covered and that the patient could be billed?

  1. Assignment of benefits
  2. Advance directive
  3. Notice of Privacy Practices
  4. Advance Beneficiary Notice Correct answer.

Explanation

The Advance Beneficiary Notice of Noncoverage, or ABN, transfers potential financial liability to a Medicare beneficiary when the provider expects Medicare to deny payment as not medically necessary. Without an ABN, the provider generally cannot bill the beneficiary for that service. Advance directives and privacy notices serve unrelated purposes.

Question 8Patient Access Operations and Front-End Revenue Cycle

A patient scheduled for next week tells the registrar he cannot pay his $1,200 estimated balance at the time of service. What is the most appropriate front-end action?

  1. Cancel the appointment and ask the patient to call back once he can pay in full
  2. Register the patient as a bad-debt write-off before the service occurs
  3. Ask the patient to sign a waiver stating he refuses financial responsibility for the visit
  4. Screen for financial assistance and set up a payment plan Correct answer.

Explanation

Front-end staff should connect patients who cannot pay with financial assistance screening and a documented payment arrangement before the date of service. Denying or postponing medically indicated care for inability to pay creates access and compliance problems. Bad debt is recorded only after collection efforts fail, not in advance.

Question 9Patient Access Operations and Front-End Revenue Cycle

A child is covered as a dependent under both parents' plans, and both plans follow the birthday rule. The father's birthday is March 4 and the mother's is March 12. Which plan is primary?

  1. The plan that enrolled the child first
  2. The father's plan, because his birthday is earlier in the year Correct answer.
  3. The mother's plan, because the mother is generally considered the custodial parent
  4. The plan with the higher deductible

Explanation

Under the birthday rule, the plan of the parent whose birthday falls earlier in the calendar year pays first for a dependent child, regardless of which parent is older or earns more. The other parent's plan then considers the remaining balance. Enrollment date and plan cost do not determine primary status under this rule.

Question 10Patient Access Operations and Front-End Revenue Cycle

An electronic eligibility response shows the patient's coverage is active, with a $2,000 deductible and $0 met. Which conclusion is correct?

  1. The plan will pay the full allowed amount
  2. The claim will be denied automatically because the deductible has not been met yet
  3. Coverage is active, but the patient may owe toward the deductible Correct answer.
  4. The patient has no active coverage

Explanation

An active response confirms the plan will adjudicate the claim, and the deductible fields show how much the patient likely owes before cost sharing begins. Services may still be covered, with the patient responsible for allowed charges up to the unmet deductible. The response does not indicate a denial or an absence of coverage.

Question 11Patient Access Operations and Front-End Revenue Cycle

A payer's authorization expires 30 days after issue, and the procedure is scheduled 45 days out. What is the best front-end action?

  1. Collect the full charge from the patient as a deposit in case the claim denies
  2. Tell the patient to reschedule sooner so the current authorization remains valid
  3. Submit the claim now and ask the payer to hold it until the service date
  4. Obtain the authorization closer to the date of service Correct answer.

Explanation

An authorization must be valid on the date the service is actually rendered, so timing the request so that approval covers the scheduled date avoids a preventable denial. Rescheduling for the payer's convenience is not a front-end obligation. Claims cannot be submitted before the service occurs.

Question 12Patient Access Operations and Front-End Revenue Cycle

A woman in active labor arrives at the emergency department with no insurance. Under EMTALA, the hospital must:

  1. Transfer her to the nearest public facility before any treatment is provided
  2. Register her as self-pay and obtain a signed payment agreement first
  3. Provide screening and stabilizing treatment regardless of ability to pay Correct answer.
  4. Collect a deposit from a family member before triage begins

Explanation

EMTALA requires a medical screening examination and stabilizing treatment for anyone who presents with an emergency medical condition, including active labor, without regard to insurance or ability to pay. Registration and payment discussions occur after the screening and stabilization. Transfer is permitted only when the patient is stabilized or the transfer meets specific legal criteria.

Question 13Patient Access Operations and Front-End Revenue Cycle

A patient presents a Medicare Advantage card at check-in. Where should the claim be billed?

  1. The state Medicaid agency
  2. The patient's supplemental Medigap plan
  3. The Medicare administrative contractor
  4. The Medicare Advantage plan Correct answer.

Explanation

Under Medicare Advantage, the private plan contracts with Medicare to administer benefits and receives the claim instead of original Medicare. Billing the Medicare administrative contractor would route the claim to fee-for-service Medicare. Medigap pays only after the primary Medicare coverage has adjudicated.

Question 14Patient Access Operations and Front-End Revenue Cycle

An HMO patient scheduled with a specialist without the required PCP referral. What is the best action?

  1. See the patient and bill the visit as self-pay
  2. Bill the visit to Medicaid instead
  3. Cancel the visit and tell the patient to find a new specialist
  4. Contact the PCP to obtain the referral before the visit Correct answer.

Explanation

When a plan requires a referral, the correct fix is to secure it from the primary care clinician before the encounter so the service is covered. Billing the patient as self-pay for a plan requirement is inappropriate and often noncompliant. Cancelling the visit or billing a different payer does not resolve the missing authorization.

Question 15Patient Access Operations and Front-End Revenue Cycle

A procedure has an allowed amount of $1,000. The patient has $200 remaining on a deductible and 20% coinsurance. What is the patient's total responsibility?

  1. $360 Correct answer.
  2. $200
  3. $500
  4. $160

Explanation

The patient first pays the remaining deductible of $200, leaving $800 of the allowed amount. Coinsurance of 20% then applies to the $800, which is $160. Adding both gives a patient responsibility of $360.

Question 16Patient Access Operations and Front-End Revenue Cycle

Which practice most effectively reduces no-shows among patients at high risk of missing appointments?

  1. Offering only same-day appointments to all patients
  2. Requiring full prepayment for every visit, including routine follow-ups
  3. Confirming by text a few days ahead and offering easy rescheduling Correct answer.
  4. Mailing a paper reminder notice two weeks before the scheduled visit

Explanation

Timely, interactive reminder contacts close to the appointment date, paired with a simple way to reschedule, allow open slots to be filled and are consistently effective at reducing no-shows. Mailed notices sent well in advance are easily forgotten. Payment mandates and same-day-only access create barriers rather than improving attendance.

Question 17Patient Access Operations and Front-End Revenue Cycle

When must a patient receive the Notice of Privacy Practices?

  1. Annually, by mail, along with the patient statement
  2. Only when the patient signs a release of information
  3. At the first service delivery, with acknowledgment obtained Correct answer.
  4. Only when the patient requests a copy in writing from the privacy officer

Explanation

Covered entities must give patients the Notice of Privacy Practices no later than the first date of service and make a good faith effort to obtain written acknowledgment of receipt. It is not limited to patients who ask or who sign an authorization. There is no general requirement to mail it annually.

Question 18Patient Access Operations and Front-End Revenue Cycle

A patient with limited English proficiency arrives for registration. Which approach meets best practice?

  1. Ask the patient's adult child to interpret the registration interview
  2. Speak slowly in English and use hand gestures
  3. Ask a bilingual employee from another department to help
  4. Use a qualified medical interpreter in person or by phone or video Correct answer.

Explanation

Language access standards call for a qualified interpreter, in person or through telephone or video services, for patients with limited English proficiency. Family members and untrained staff should not interpret, particularly for consent, financial, or clinical information. Relying on gestures or slowed speech risks misunderstandings that affect safety and payment.

Question 19Patient Access Operations and Front-End Revenue Cycle

A Medicare beneficiary is placed in observation status for more than 24 hours. Which notice must the hospital provide?

  1. Notice of Privacy Practices
  2. Important Message from Medicare
  3. Advance Beneficiary Notice of Noncoverage
  4. Medicare Outpatient Observation Notice Correct answer.

Explanation

The Medicare Outpatient Observation Notice must be delivered to Medicare beneficiaries who receive observation services for more than 24 hours, explaining that they are outpatients and may face different cost-sharing. The Important Message from Medicare applies to inpatient status and discharge rights. An ABN covers expected noncoverage of a specific service.

Question 20Patient Access Operations and Front-End Revenue Cycle

A patient asks to be registered under a name that does not match the photo ID presented. What is the best action?

  1. Resolve the discrepancy per identity verification policy before registering Correct answer.
  2. Make a copy of the ID and complete the registration without commenting on the mismatch
  3. Register the patient as self-pay and collect payment
  4. Refuse to register the patient and ask them to leave

Explanation

Name and identity discrepancies must be resolved following the facility's identity verification and medical record integrity policy before a record is created or used. Proceeding without addressing the mismatch risks duplicate records, misidentification, and billing errors. Denying care outright is not the appropriate first step when the discrepancy may be explainable.

Question 21Patient Access Operations and Front-End Revenue Cycle

An uninsured patient schedules an elective procedure three weeks in advance and asks what it will cost. Under the No Surprises Act, the provider should:

  1. Provide the estimate only after the service is rendered
  2. Give a good faith estimate of expected charges within the required timeframe Correct answer.
  3. Explain that uninsured patients are not legally entitled to an estimate of charges
  4. Provide the estimate only if the patient pays in full that day

Explanation

The No Surprises Act requires providers to furnish an uninsured or self-pay patient a good faith estimate of expected charges, either on request or at scheduling, within the required timeframe. The estimate must be provided before the service, not after. It is not conditioned on payment or on any particular coverage status.

Question 22Patient Access Operations and Front-End Revenue Cycle

A patient injured in a motor vehicle collision presents with Medicare and auto medical payments coverage. Which payer is primary for the injury-related care?

  1. The patient, who pays and then seeks reimbursement
  2. Medicaid, because the patient has limited income
  3. The auto insurer's medical payments coverage Correct answer.
  4. Medicare, because federal programs always pay first

Explanation

Medicare is secondary to no-fault and liability insurance, including auto medical payments coverage, for injury-related services. The auto carrier is billed first and Medicare considers payment only after that coverage is exhausted or denies. Front-end screening for accident-related coverage is therefore essential to correct payer order.

Question 23Patient Access Operations and Front-End Revenue Cycle

A payer requires notification within 24 hours of an inpatient admission. The patient is admitted Friday at 8 p.m. and the office reopens Monday. What is the best action?

  1. Take no action because the payer's office is closed
  2. Notify the payer Monday morning and document the reason for the delay
  3. Ask the patient to call the payer on Monday
  4. Call the payer's after-hours or online notification line within 24 hours Correct answer.

Explanation

Most payers provide an after-hours or online notification channel so that the 24-hour requirement can be met when the office is closed. Missing the notification window can cause a denial or reduced payment that is largely preventable. Documenting a delay or delegating the call to the patient does not satisfy the requirement.

Question 24Patient Access Operations and Front-End Revenue Cycle

During registration, staff find an existing medical record for the patient under a slightly different spelling of the name. What is the best action?

  1. Register under both records and let billing choose
  2. Confirm identity and follow the duplicate-record policy before registering Correct answer.
  3. Create a new medical record because the spelling of the name does not match exactly
  4. Use the new record and merge the two records later

Explanation

When a possible existing record is identified, staff must verify identity and then follow the facility's duplicate record and merge policy so that clinical history and claims stay with the correct patient. Creating another record fragments the chart and can cause safety and billing errors. Anyone may present under a variant spelling, so the mismatch alone is not decisive.

Question 25Patient Access Operations and Front-End Revenue Cycle

A patient with a high-deductible health plan and a health savings account asks why the full allowed amount for a non-preventive visit is due. What is the correct explanation?

  1. The claim was denied as not medically necessary
  2. HSA funds cannot be used for outpatient visits
  3. The plan pays nothing until the deductible is met, except for preventive care Correct answer.
  4. Because the provider is out of network, the plan cannot be billed and the visit is not covered

Explanation

With a high-deductible health plan, the enrollee generally pays the allowed charges until the deductible is satisfied, while certain preventive services may be covered before the deductible. The patient may use health savings account funds to pay those amounts. A deductible is not a denial, and the scenario gives no indication of a network problem.

Question 26Patient Access Operations and Front-End Revenue Cycle

Which function is performed during the front-end revenue cycle?

  1. Denial management and appeals
  2. Claim adjudication and payment posting
  3. Bad debt write-off and collection agency placement
  4. Scheduling, registration, and insurance verification Correct answer.

Explanation

Front-end revenue cycle includes pre-service activities such as scheduling, registration, eligibility verification, and financial clearance. Claim adjudication, denial management, and bad-debt placement occur later in the revenue cycle.

Question 27Patient Access Operations and Front-End Revenue Cycle

What is the recommended practice to prevent duplicate medical records at registration?

  1. Use at least two patient identifiers during every search Correct answer.
  2. Rely on the insurance member ID as the only identifier
  3. Create a new record whenever the address changes
  4. Search the master patient index using only the patient's last name

Explanation

Using at least two identifiers, such as full name and date of birth, reduces the chance of selecting or creating the wrong record. A last-name-only search is too broad and can cause overlays or duplicates.

Question 28Patient Access Operations and Front-End Revenue Cycle

Which document is the best primary source for verifying a patient's identity at check-in?

  1. The patient's insurance card
  2. A government-issued photo identification Correct answer.
  3. A signed consent form
  4. A recent utility bill

Explanation

A government-issued photo ID is the strongest primary identity document because it includes a photograph and unique identifiers. Insurance cards, utility bills, and consent forms do not reliably prove identity.

Question 29Patient Access Operations and Front-End Revenue Cycle

A copayment is best described as which type of patient financial responsibility?

  1. A percentage of allowed charges after the deductible
  2. A monthly premium paid to the health plan
  3. The total annual amount an insurer will pay
  4. A fixed dollar amount paid at the time of service Correct answer.

Explanation

A copayment is a fixed dollar amount the patient pays for a covered service, often at the time of service. It is different from coinsurance, premiums, and annual maximums.

Question 30Patient Access Operations and Front-End Revenue Cycle

Which document describes how a covered entity may use and disclose a patient's protected health information?

  1. Important Message from Medicare
  2. Medicare Outpatient Observation Notice
  3. Advance Beneficiary Notice
  4. Notice of Privacy Practices Correct answer.

Explanation

The Notice of Privacy Practices explains permitted uses and disclosures of protected health information and the patient's privacy rights. The ABN, MOON, and IM address Medicare notice requirements, not general privacy practices.

Question 31Patient Access Operations and Front-End Revenue Cycle

What does a real-time eligibility transaction primarily confirm?

  1. Whether the service is medically necessary
  2. Whether the provider is credentialed with the payer
  3. Whether the claim will be paid at the contracted rate
  4. Whether the patient's coverage is active and what benefits apply Correct answer.

Explanation

Eligibility verification confirms active coverage and benefit details such as copay, deductible, and coinsurance. It does not guarantee payment or establish medical necessity.

Question 32Patient Access Operations and Front-End Revenue Cycle

A patient arrives without an insurance card but states they have coverage. What should access staff do first?

  1. Reschedule the appointment until the card is found
  2. Ask for alternate proof of coverage or verify eligibility electronically Correct answer.
  3. Register the patient as self-pay and collect the full charge
  4. Bill the employer directly for the visit

Explanation

When a patient lacks a card, staff should try to obtain alternate proof or use electronic eligibility verification. Registering as self-pay immediately may cause incorrect billing and financial hardship.

Question 33Patient Access Operations and Front-End Revenue Cycle

A deductible is the amount a patient must pay before which event occurs?

  1. The payer issues an authorization
  2. The provider submits a claim
  3. The health plan begins paying covered benefits Correct answer.
  4. The patient can schedule an appointment

Explanation

A deductible is the amount the patient pays for covered services before the health plan begins to pay benefits. Copays and coinsurance may apply after the deductible is met.

Question 34Patient Access Operations and Front-End Revenue Cycle

A 68-year-old patient is still working and has coverage through an employer with 25 employees. Which payer is primary under Medicare Secondary Payer rules?

  1. Medicare Part A
  2. Medicaid
  3. The employer group health plan Correct answer.
  4. Medicare Part B

Explanation

For working-aged beneficiaries, Medicare is secondary when the employer has 20 or more employees and coverage is based on current employment. The employer group health plan is primary in that situation.

Question 35Patient Access Operations and Front-End Revenue Cycle

A patient schedules an MRI that the payer requires to be prior-authorized. What is the best front-end action?

  1. Register the patient as self-pay to avoid the authorization
  2. Verify the authorization requirement and obtain approval before the service Correct answer.
  3. Tell the patient to obtain the authorization from the payer
  4. Schedule the MRI and request authorization after the visit

Explanation

The authorization should be verified and obtained before the scheduled service to prevent denial and unexpected patient liability. Retroactive authorization is not guaranteed and may not be accepted.

Question 36Patient Access Operations and Front-End Revenue Cycle

Which form is used at registration to gather information that helps determine whether Medicare or another payer is primary?

  1. Advance Beneficiary Notice
  2. Notice of Privacy Practices
  3. Good Faith Estimate
  4. Medicare Secondary Payer questionnaire Correct answer.

Explanation

The Medicare Secondary Payer questionnaire collects information about other coverage, employment, and disability to determine payer order. It is a required front-end tool for Medicare beneficiaries.

Question 37Patient Access Operations and Front-End Revenue Cycle

A minor is brought to registration by a grandparent. What should staff confirm before obtaining consent for non-emergency treatment?

  1. The grandparent has legal authority to consent, such as guardianship Correct answer.
  2. The grandparent has the child's insurance card
  3. The child has a school identification number
  4. The grandparent knows the child's date of birth

Explanation

For non-emergency care of a minor, consent must come from a parent or legal guardian. A grandparent needs documented legal authority unless the situation is an emergency.

Question 38Patient Access Operations and Front-End Revenue Cycle

An HMO patient arrives with a specialist referral that names a different specialist than the one scheduled. What should access staff do?

  1. Obtain a corrected referral before the visit Correct answer.
  2. Ask the patient to pay cash and ignore the referral
  3. Cancel the patient's primary care assignment
  4. Proceed with the visit and let the specialist sort it out

Explanation

A referral must match the specialist and service being provided; otherwise the HMO may deny coverage. The front-end team should obtain a corrected referral before the visit.

Question 39Patient Access Operations and Front-End Revenue Cycle

Which front-end practice most directly supports submission of a clean claim?

  1. Verifying demographics and insurance information at each registration Correct answer.
  2. Waiting for the payer to request missing information
  3. Using abbreviations and nicknames for patient names
  4. Collecting the entire balance before every visit

Explanation

A clean claim depends on accurate patient and insurance data captured at registration. Collecting cash or waiting for payer follow-up does not correct front-end data errors.

Question 40Patient Access Operations and Front-End Revenue Cycle

A patient has both Medicaid and a commercial health plan. Which payer is generally considered the payer of last resort?

  1. Medicare Part A
  2. Medicaid Correct answer.
  3. The commercial health plan
  4. The patient's auto medical payments coverage

Explanation

Medicaid is generally the payer of last resort when other coverage exists. Commercial plans and Medicare typically pay before Medicaid.

Question 41Patient Access Operations and Front-End Revenue Cycle

A patient with a large hospital balance asks about a payment plan. What should the financial counselor do first?

  1. Send the account to a collection agency
  2. Screen the patient for financial assistance or charity care Correct answer.
  3. Deny the payment plan because the balance is too high
  4. Require full payment before discussing options

Explanation

Financial counselors should first identify whether the patient qualifies for financial assistance or charity care. Payment plans are considered after screening and discussing available options.

Question 42Patient Access Operations and Front-End Revenue Cycle

What is the main purpose of the Red Flags Rule in patient access?

  1. To verify medical necessity for scheduled services
  2. To help staff detect and respond to possible identity theft Correct answer.
  3. To set allowable charges for self-pay patients
  4. To manage appointment no-show rates

Explanation

The Red Flags Rule requires creditors, including many healthcare providers, to have programs to detect and respond to identity theft indicators. It is not a medical necessity or pricing rule.

Question 43Patient Access Operations and Front-End Revenue Cycle

A patient needs an urgent procedure tomorrow, but the payer's prior authorization is still pending. What is the best action?

  1. Submit the claim without authorization and hope for payment
  2. Register the patient as self-pay without telling them
  3. Cancel the procedure until the authorization is approved
  4. Escalate to the payer for expedited review and document the status Correct answer.

Explanation

When a service is urgent and authorization is pending, access staff should request expedited review and document the payer response. Proceeding without authorization or misregistering the patient can create compliance and financial risks.

Question 44Patient Access Operations and Front-End Revenue Cycle

A patient's employer plan has a $30 copay for primary care and 20% coinsurance for specialist visits. What should access staff tell the patient to expect at a specialist visit?

  1. A fixed $30 payment
  2. No payment because the plan is active
  3. The full charge until the annual maximum is met
  4. 20% of the allowed amount after any deductible Correct answer.

Explanation

Coinsurance is a percentage of the allowed amount that the patient pays after any deductible is met. It is not a fixed copay or the full charge.

Question 45Patient Access Operations and Front-End Revenue Cycle

What right does the Important Message from Medicare explain to a hospitalized Medicare beneficiary?

  1. The right to choose a Medicare Advantage plan at discharge
  2. The right to appeal a hospital discharge decision Correct answer.
  3. The right to receive a Good Faith Estimate
  4. The right to refuse to pay coinsurance

Explanation

The Important Message from Medicare informs beneficiaries of their right to appeal a hospital discharge. It is separate from the ABN, NPP, and observation notice.

Question 46Patient Access Operations and Front-End Revenue Cycle

A patient with end-stage renal disease becomes eligible for Medicare and also has an employer group health plan. Under Medicare Secondary Payer rules, which payer is primary during the first 30 months of Medicare eligibility?

  1. The employer group health plan Correct answer.
  2. Medicaid
  3. The patient's supplemental policy
  4. Medicare

Explanation

For beneficiaries with end-stage renal disease, the employer group health plan is primary during the 30-month coordination period. Medicare becomes secondary during that time.

Question 47Patient Access Operations and Front-End Revenue Cycle

A 70-year-old patient is actively working for an employer with 15 employees. Which statement is correct about Medicare Secondary Payer rules?

  1. Medicaid becomes primary because the employer is small
  2. Medicare is primary because the employer has fewer than 20 employees Correct answer.
  3. The employer plan is always primary because the patient is working
  4. The patient may choose either payer as primary

Explanation

When an employer has fewer than 20 employees, Medicare is primary for a working-aged beneficiary. The small-group exception reverses the usual working-aged rule.

Question 48Patient Access Operations and Front-End Revenue Cycle

A valid Advance Beneficiary Notice is signed before a service that Medicare may not cover. If Medicare denies the service as not medically necessary, what may the provider do?

  1. Bill Medicaid as primary regardless of eligibility
  2. Bill Medicare again for the same service
  3. Write off the entire charge
  4. Bill the patient for the service according to the ABN Correct answer.

Explanation

A valid ABN shifts financial liability to the patient if Medicare denies the service as not medically necessary. The provider may then bill the patient according to the notice.

Question 49Patient Access Operations and Front-End Revenue Cycle

An uninsured patient schedules a service 12 business days in advance. Under the No Surprises Act, when should the provider furnish a Good Faith Estimate?

  1. Within 30 days after the service
  2. Only if the patient asks after the service
  3. Within 3 business days after scheduling Correct answer.
  4. At the time of check-in on the day of service

Explanation

For services scheduled at least 10 business days in advance, the Good Faith Estimate must be provided within 3 business days after scheduling. A 12-business-day lead time meets that threshold.

Question 50Patient Access Operations and Front-End Revenue Cycle

Which front-end error is most likely to cause a claim denial that could have been prevented during registration?

  1. Entering an inactive insurance plan without verifying eligibility Correct answer.
  2. Obtaining a referral before the specialist visit
  3. Using the correct patient date of birth
  4. Collecting a copay at time of service

Explanation

Entering an inactive plan without eligibility verification commonly causes front-end denials. Correct registration data, including coverage status, is essential to clean claim submission.