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CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) 2025/2026 ACTUAL EXAM
COMPLETE 350 QUESTIONS WITH DETAILED VERIFIED ANSWERS (100% CORRECT
ANSWERS) /ALREADY GRADED A+
How does the term carve-out used when discussing managed care? - ANSWER - To refer to
specific benefits or services
Identify some key drivers of increasing healthcare costs - ANSWER - -Demographics -
Chronic Conditions -Provider payment systems - Provider payment systems that are
designed to reward volume rather than quality, outcomes, and prevention -Consumer
Perceptions -Health Plan pressure -Physician Relationships -Supply Chain
Identify some key drivers of increasing healthcare costs - ANSWER - Demographics
Chronic Conditions Provider payment systems - Provider payment systems that are
designed to reward volume rather than quality, outcomes, and prevention Consumer
Perceptions Health Plan Pressure Physician Relationships Supply Chain
Identify the various types of government‐sponsored health coverage: - ANSWER - Medicare
- Government; Beneficiaries enrolled in such plans, but participation in these plans is
voluntary. Medicaid Managed Care - Medicaid beneficiaries are required to select and
enroll in a managed care plan. Medicare Managed Care (a.k.a. Medicare Advantage Plans)
Identify the various types of government‐sponsored health coverage. - ANSWER - -
Medicare - Government; Beneficiaries enrolled in such plans, but participation in these
plans is voluntary. -Medicaid -Medicaid Managed Care - Medicaid beneficiaries are
required to select and enroll in a managed care plan. -Medicare Managed Care (a.k.a.
Medicare Advantage Plans)
Identify the various types of private health plan coverage - ANSWER - HMO Conventional
PPO and POS HDHP/SO plans - high-deductible health plans with a savings option; Private
- Include higher patient out-of-pocket expenditures for treatments that can serve to reduce
utilization/costs.
Identify the various types of private health plan coverage. - ANSWER - -HMO -Conventional
-PPO and POS -(HDHP/SO) plans - high-deductible health plans with a savings option;
Private - Include higher patient out-of-pocket expenditures for treatments that can serve to
reduce utilization/costs
Identify which initiatives are focused on to help increase an organization's revenue/profit
/margins. - ANSWER - -Health plan consolidation -Payment policing and standardization of
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contract requirements -Shift in volume and cost risk to hospitals -Contract performance
modeling
Identify which option(s) is a benefit for CDHP consumers. - ANSWER - -Coverage -Choice -
Access
Identify which options are a benefit for HSA consumers. - ANSWER - -It is transportable,
allowing workers access from one job to the next. -Both employees and employers can
contribute pretax dollars to the qualified account. -They are available to everyone, not just
employees of small businesses or the self- employed.
Information required for claims processing includes the following: - ANSWER - -Patient
and/or enrollee identification, DOB, and sex -Assigned group -Provider or referring provider
identification, as appropriate –Date of service -Type of service -Type of diagnosis/major
diagnostic category -Procedure code(s): CPT and HCPCS codes -COB information ▪
Primary, secondary, and other diagnosis codes as necessary (as many as five may be
needed under DRGs for hospital reimbursement), including -DRG classification -Episode
of care identifier -Revenue center (UB‐04) code for hospitalization
Managed care organizations (MCO) exist primarily in four forms: - ANSWER - Health
Maintenance Organizations (HMO) Preferred Provider Organizations (PPO) Point of Service
(POS) Organizations Exclusive Provider Organizations (EPO)
Managed Medicare enrollees now enjoy patient protections such as the following: -
ANSWER - a) Information disclosure b) Choice of providers and plans c) Access to
emergency services d) Participation in treatment decisions e) Financial disclosure f)
Respect and nondiscrimination g) Confidentiality of health information h) Complaints and
appeals
M care Part A (Hospital Insurance) - ANSWER - -covers most medically necessary hospital,
skilled nursing facility, home health, and hospice care services. -It is free if you have
worked and paid Social Security taxes for at least 40 calendar quarters (10 years); those
who have worked and paid taxes for less than 40 calendar quarters (10 years) are required
to pay a fee
M care Part B (Medical Insurance) - ANSWER - covers most medically necessary doctors'
services, preventive care, durable medical equipment, hospital outpatient services,
laboratory tests, x-rays, mental health care, and some home health and ambulance
services. An additional monthly premium is paid for this coverage.
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M care Part C (Advantage) - ANSWER - -allows private health insurance companies to
provide Medicare benefits. -These Medicare private health plans are known as Medicare
Advantage Plans. These plans must offer at least the same benefits as Original Medicare
(those covered under Parts A and B) but can do so with different rules, costs, and coverage
restrictions. -Medicare Part C may also offer additional health coverage benefits; you
typically obtain Part D as part of a Medicare Advantage benefits package. --You may pay a
monthly premium for this coverage, in addition to your Part B premium.
M care Part D (Prescription) - ANSWER - -outpatient prescription drug insurance, was
established by the Medicare Prescription Drug, Improvement, and Modernization Act
(MMA) on January 1, 2006. -Part D is provided only through private insurance companies
that have contracts with the government—it is never provided directly by the government
(like original Medicare is).
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - ANSWER - Total
Medical Expenses divided by Total Premiums
Medicare - ANSWER - -Part A - provides inpatient/hospital, hospice, and skilled nursing
coverage -Part B - provides outpatient/medical coverage -Part C - an alternative way to
receive your Medicare benefits (known as Medicare Advantage) -Part D - prescription drug
coverage
Medicare is composed of four parts: - ANSWER - Part A - provides inpatient/hospital,
hospice, and skilled nursing coverage Part B - provides outpatient/medical coverage Part C
- an alternative way to receive your Medicare benefits (known as Medicare Advantage) Part
D - prescription drug coverage
Medicare Outpatient Observation Notice (MOON) - ANSWER - -requires hospitals and
Critical Access Hospitals (CAH) to provide notification to individuals receiving observation
services as outpatients for more than 24 hours explaining the status of the individual as an
outpatient, not an inpatient, and the implications of such status. -Requirements - The
MOON must be provided no later than 36 hours after observation services are initiated or,
if sooner, upon release. An oral explanation of the MOON must be provided, ideally in
conjunction with the delivery of the notice, and a signature must be obtained from the
individual, or a person acting on such individual's behalf, to acknowledge receipt. In cases
where such individual or person refuses to sign the MOON, the staff member of the
hospital or CAH providing the notice must sign the notice to certify that notification was
presented.
CSPR - CERTIFIED SPECIALIST PAYMENT REP (HFMA) 2025/2026 ACTUAL EXAM
COMPLETE 350 QUESTIONS WITH DETAILED VERIFIED ANSWERS (100% CORRECT
ANSWERS) /ALREADY GRADED A+
How does the term carve-out used when discussing managed care? - ANSWER - To refer to
specific benefits or services
Identify some key drivers of increasing healthcare costs - ANSWER - -Demographics -
Chronic Conditions -Provider payment systems - Provider payment systems that are
designed to reward volume rather than quality, outcomes, and prevention -Consumer
Perceptions -Health Plan pressure -Physician Relationships -Supply Chain
Identify some key drivers of increasing healthcare costs - ANSWER - Demographics
Chronic Conditions Provider payment systems - Provider payment systems that are
designed to reward volume rather than quality, outcomes, and prevention Consumer
Perceptions Health Plan Pressure Physician Relationships Supply Chain
Identify the various types of government‐sponsored health coverage: - ANSWER - Medicare
- Government; Beneficiaries enrolled in such plans, but participation in these plans is
voluntary. Medicaid Managed Care - Medicaid beneficiaries are required to select and
enroll in a managed care plan. Medicare Managed Care (a.k.a. Medicare Advantage Plans)
Identify the various types of government‐sponsored health coverage. - ANSWER - -
Medicare - Government; Beneficiaries enrolled in such plans, but participation in these
plans is voluntary. -Medicaid -Medicaid Managed Care - Medicaid beneficiaries are
required to select and enroll in a managed care plan. -Medicare Managed Care (a.k.a.
Medicare Advantage Plans)
Identify the various types of private health plan coverage - ANSWER - HMO Conventional
PPO and POS HDHP/SO plans - high-deductible health plans with a savings option; Private
- Include higher patient out-of-pocket expenditures for treatments that can serve to reduce
utilization/costs.
Identify the various types of private health plan coverage. - ANSWER - -HMO -Conventional
-PPO and POS -(HDHP/SO) plans - high-deductible health plans with a savings option;
Private - Include higher patient out-of-pocket expenditures for treatments that can serve to
reduce utilization/costs
Identify which initiatives are focused on to help increase an organization's revenue/profit
/margins. - ANSWER - -Health plan consolidation -Payment policing and standardization of
,2 of 19
contract requirements -Shift in volume and cost risk to hospitals -Contract performance
modeling
Identify which option(s) is a benefit for CDHP consumers. - ANSWER - -Coverage -Choice -
Access
Identify which options are a benefit for HSA consumers. - ANSWER - -It is transportable,
allowing workers access from one job to the next. -Both employees and employers can
contribute pretax dollars to the qualified account. -They are available to everyone, not just
employees of small businesses or the self- employed.
Information required for claims processing includes the following: - ANSWER - -Patient
and/or enrollee identification, DOB, and sex -Assigned group -Provider or referring provider
identification, as appropriate –Date of service -Type of service -Type of diagnosis/major
diagnostic category -Procedure code(s): CPT and HCPCS codes -COB information ▪
Primary, secondary, and other diagnosis codes as necessary (as many as five may be
needed under DRGs for hospital reimbursement), including -DRG classification -Episode
of care identifier -Revenue center (UB‐04) code for hospitalization
Managed care organizations (MCO) exist primarily in four forms: - ANSWER - Health
Maintenance Organizations (HMO) Preferred Provider Organizations (PPO) Point of Service
(POS) Organizations Exclusive Provider Organizations (EPO)
Managed Medicare enrollees now enjoy patient protections such as the following: -
ANSWER - a) Information disclosure b) Choice of providers and plans c) Access to
emergency services d) Participation in treatment decisions e) Financial disclosure f)
Respect and nondiscrimination g) Confidentiality of health information h) Complaints and
appeals
M care Part A (Hospital Insurance) - ANSWER - -covers most medically necessary hospital,
skilled nursing facility, home health, and hospice care services. -It is free if you have
worked and paid Social Security taxes for at least 40 calendar quarters (10 years); those
who have worked and paid taxes for less than 40 calendar quarters (10 years) are required
to pay a fee
M care Part B (Medical Insurance) - ANSWER - covers most medically necessary doctors'
services, preventive care, durable medical equipment, hospital outpatient services,
laboratory tests, x-rays, mental health care, and some home health and ambulance
services. An additional monthly premium is paid for this coverage.
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M care Part C (Advantage) - ANSWER - -allows private health insurance companies to
provide Medicare benefits. -These Medicare private health plans are known as Medicare
Advantage Plans. These plans must offer at least the same benefits as Original Medicare
(those covered under Parts A and B) but can do so with different rules, costs, and coverage
restrictions. -Medicare Part C may also offer additional health coverage benefits; you
typically obtain Part D as part of a Medicare Advantage benefits package. --You may pay a
monthly premium for this coverage, in addition to your Part B premium.
M care Part D (Prescription) - ANSWER - -outpatient prescription drug insurance, was
established by the Medicare Prescription Drug, Improvement, and Modernization Act
(MMA) on January 1, 2006. -Part D is provided only through private insurance companies
that have contracts with the government—it is never provided directly by the government
(like original Medicare is).
Medical Cost Ratio (MCR) or Medical Loss Ratio (MLR) is defined as: - ANSWER - Total
Medical Expenses divided by Total Premiums
Medicare - ANSWER - -Part A - provides inpatient/hospital, hospice, and skilled nursing
coverage -Part B - provides outpatient/medical coverage -Part C - an alternative way to
receive your Medicare benefits (known as Medicare Advantage) -Part D - prescription drug
coverage
Medicare is composed of four parts: - ANSWER - Part A - provides inpatient/hospital,
hospice, and skilled nursing coverage Part B - provides outpatient/medical coverage Part C
- an alternative way to receive your Medicare benefits (known as Medicare Advantage) Part
D - prescription drug coverage
Medicare Outpatient Observation Notice (MOON) - ANSWER - -requires hospitals and
Critical Access Hospitals (CAH) to provide notification to individuals receiving observation
services as outpatients for more than 24 hours explaining the status of the individual as an
outpatient, not an inpatient, and the implications of such status. -Requirements - The
MOON must be provided no later than 36 hours after observation services are initiated or,
if sooner, upon release. An oral explanation of the MOON must be provided, ideally in
conjunction with the delivery of the notice, and a signature must be obtained from the
individual, or a person acting on such individual's behalf, to acknowledge receipt. In cases
where such individual or person refuses to sign the MOON, the staff member of the
hospital or CAH providing the notice must sign the notice to certify that notification was
presented.
