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CHAM: Patient Access Management

CHAM · Work through your exam, one topic at a time.

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Patient Access Management

What this domain tests

Patient Access Management tests the front-end processes that create a clean financial and clinical record before service: scheduling, pre-registration, identity and eligibility verification, benefits and coordination of benefits (COB), prior authorization, medical necessity screening, consent, financial counseling, and point-of-service collections. The exam expects you to connect each step to downstream claim accuracy and patient experience.

Core rules and concepts

  • Verify identity with at least two identifiers and confirm the patient's demographic and insurance data at every encounter; avoid overwriting historical data without an audit trail.
  • Check eligibility before the visit and re-check near the date of service when coverage may change.
  • Ask the Medicare Secondary Payer (MSP) questionnaire when Medicare is involved. For a working beneficiary with active employer group coverage from an employer with 20 or more employees, the employer plan is generally primary.
  • Obtain prior authorization when the payer requires it and document the authorization number, approved units, and effective dates.
  • Use Advance Beneficiary Notice (ABN) only for Medicare items that may be denied as not medically necessary, not for services Medicare never covers.
  • Collect estimated patient responsibility at or before service when policy allows, and provide financial counseling for large balances.

Worked example

A 67-year-old presents for an outpatient MRI. Registration sees Medicare and an active employer plan. The scheduler had verified Medicare only and collected nothing. The access manager should: ask the MSP questions; document that the employer has 500 employees and the patient is currently working; verify the employer plan; obtain MRI prior authorization from the primary payer; estimate the copay and deductible; and explain the ABN only if medical necessity is uncertain. The claim goes to the employer plan first, then Medicare as secondary.

Traps

Assuming Medicare is always primary; treating prior authorization as back-office work; collecting before benefits are explained; and failing to document COB answers. These create denials and rework that are hard to reverse after service.