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CSPR CERTIFIED SPECIALIST PAYMENT
REP HFMA Actual Exam 2026/2027 Complete
Questions and Verified Answers Already Graded
A+ Pass Guaranteed - A+ Graded
SECTION 1: HEALTHCARE PAYMENT FUNDAMENTALS
Q1: A healthcare organization receives an electronic remittance advice (ERA) along with an
electronic funds transfer (EFT) from a commercial payer. The ERA shows payments and
adjustments for multiple claims. This electronic transaction is known as an:
• A. 837 transaction
• B. 835 transaction. [CORRECT]
• C. 270 transaction
• D. 277 transaction
Correct Answer: B Rationale: The 835 transaction is the electronic remittance advice (ERA)
that provides payment and adjustment information for healthcare claims (B). The 837 transaction
(A) is for claim submission. The 270 transaction (C) is for eligibility inquiry. The 277 transaction
(D) is for claim status inquiry.
Q2: Which federal program provides health coverage for individuals aged 65 and older, as well
as certain younger individuals with disabilities?
• A. Medicaid
• B. Children's Health Insurance Program (CHIP)
• C. Medicare. [CORRECT]
• D. TRICARE
Correct Answer: C Rationale: Medicare (C) is a federal program primarily for individuals aged
65+ and those with certain disabilities. Medicaid (A) is state/federal for low-income individuals.
CHIP (B) covers children in low-income families. TRICARE (D) serves military personnel and
families.
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Q3: A managed care plan requires members to select a primary care physician (PCP) who
coordinates all care and provides referrals for specialist visits. This describes which type of plan?
• A. Preferred Provider Organization (PPO)
• B. Health Maintenance Organization (HMO). [CORRECT]
• C. Exclusive Provider Organization (EPO)
• D. Point of Service (POS)
Correct Answer: B Rationale: HMOs (B) require PCP selection and referrals for specialist care.
PPOs (A) allow direct specialist access. EPOs (C) typically don't require referrals but restrict
out-of-network care. POS plans (D) combine features but usually require PCP coordination.
Q4: In the payment cycle, which step occurs immediately after claim submission?
• A. Payment posting
• B. Claim adjudication. [CORRECT]
• C. Payment reconciliation
• D. Appeals process
Correct Answer: B Rationale: Claim adjudication (B) is the payer's review process that occurs
immediately after submission. Payment posting (A) and reconciliation (C) occur after
adjudication. Appeals (D) follow if claims are denied or underpaid.
Q5: Which term describes the document sent by a payer to a provider explaining how a claim
was processed, including payments, adjustments, and denials?
• A. Electronic Funds Transfer (EFT)
• B. Explanation of Benefits (EOB). [CORRECT]
• C. Prior Authorization
• D. Fee Schedule
Correct Answer: B Rationale: The EOB (B) explains claim processing details to providers and
patients. EFT (A) refers to electronic payment transfer. Prior authorization (C) is pre-approval for
services. A fee schedule (D) lists contracted reimbursement rates.
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Q6: A payment specialist notices that a commercial payer's remittance advice indicates a
"contractual adjustment" of $500. This adjustment represents:
• A. An underpayment requiring appeal
• B. The difference between billed charges and the contracted allowed amount.
[CORRECT]
• C. A duplicate payment correction
• D. A patient responsibility amount
Correct Answer: B Rationale: Contractual adjustments (B) represent the write-off of charges
exceeding the contracted allowed amount per payer agreements. This is not an underpayment
(A), duplicate correction (C), or patient responsibility (D).
Q7: Which payer type typically offers both in-network and out-of-network benefits, with higher
cost-sharing for out-of-network services?
• A. Health Maintenance Organization (HMO)
• B. Preferred Provider Organization (PPO). [CORRECT]
• C. Exclusive Provider Organization (EPO)
• D. Indemnity plan
Correct Answer: B Rationale: PPOs (B) offer flexibility with both in-network and out-of-
network coverage, though out-of-network costs more. HMOs (A) and EPOs (C) typically don't
cover out-of-network care. Indemnity plans (D) don't have networks.
Q8: In healthcare payment terminology, "remittance" refers to:
• A. The initial claim submission to a payer
• B. The payment and adjustment information sent from payer to provider. [CORRECT]
• C. The patient's copayment at time of service
• D. The process of verifying patient eligibility
Correct Answer: B Rationale: Remittance (B) is the payment and adjustment information sent
by payers to providers, typically via ERA/EOB. It is not claim submission (A), patient copays
(C), or eligibility verification (D).
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Q9: Which government program provides healthcare coverage for active duty military personnel,
retirees, and their families?
• A. Medicare
• B. Medicaid
• C. TRICARE. [CORRECT]
• D. Veterans Health Administration (VHA)
Correct Answer: C Rationale: TRICARE (C) serves active duty military, retirees, and families.
Medicare (A) covers elderly/disabled. Medicaid (B) covers low-income populations. VHA (D)
serves veterans through VA facilities.
Q10: A payment specialist is reviewing the payment cycle workflow. Which sequence correctly
represents the standard payment cycle?
• A. Claim submission → Payment posting → Adjudication → Reconciliation
• B. Claim submission → Adjudication → Payment/denial → Reconciliation → Appeal (if
needed). [CORRECT]
• C. Adjudication → Claim submission → Payment posting → Reconciliation
• D. Reconciliation → Claim submission → Adjudication → Payment posting
Correct Answer: B Rationale: The standard cycle (B) is: submit claim, payer adjudicates,
payment or denial occurs, reconciliation follows, and appeals happen if necessary. Other
sequences misorder critical steps.
Q11: Which transaction set is used to electronically submit healthcare claims to payers?
• A. 835
• B. 837. [CORRECT]
• C. 270/271
• D. 276/277
Correct Answer: B Rationale: The 837 transaction (B) is the standard for electronic claim
submission. The 835 (A) is for remittance advice. 270/271 (C) handles eligibility. 276/277 (D)
manages claim status inquiry/response.
CSPR CERTIFIED SPECIALIST PAYMENT
REP HFMA Actual Exam 2026/2027 Complete
Questions and Verified Answers Already Graded
A+ Pass Guaranteed - A+ Graded
SECTION 1: HEALTHCARE PAYMENT FUNDAMENTALS
Q1: A healthcare organization receives an electronic remittance advice (ERA) along with an
electronic funds transfer (EFT) from a commercial payer. The ERA shows payments and
adjustments for multiple claims. This electronic transaction is known as an:
• A. 837 transaction
• B. 835 transaction. [CORRECT]
• C. 270 transaction
• D. 277 transaction
Correct Answer: B Rationale: The 835 transaction is the electronic remittance advice (ERA)
that provides payment and adjustment information for healthcare claims (B). The 837 transaction
(A) is for claim submission. The 270 transaction (C) is for eligibility inquiry. The 277 transaction
(D) is for claim status inquiry.
Q2: Which federal program provides health coverage for individuals aged 65 and older, as well
as certain younger individuals with disabilities?
• A. Medicaid
• B. Children's Health Insurance Program (CHIP)
• C. Medicare. [CORRECT]
• D. TRICARE
Correct Answer: C Rationale: Medicare (C) is a federal program primarily for individuals aged
65+ and those with certain disabilities. Medicaid (A) is state/federal for low-income individuals.
CHIP (B) covers children in low-income families. TRICARE (D) serves military personnel and
families.
,2
Q3: A managed care plan requires members to select a primary care physician (PCP) who
coordinates all care and provides referrals for specialist visits. This describes which type of plan?
• A. Preferred Provider Organization (PPO)
• B. Health Maintenance Organization (HMO). [CORRECT]
• C. Exclusive Provider Organization (EPO)
• D. Point of Service (POS)
Correct Answer: B Rationale: HMOs (B) require PCP selection and referrals for specialist care.
PPOs (A) allow direct specialist access. EPOs (C) typically don't require referrals but restrict
out-of-network care. POS plans (D) combine features but usually require PCP coordination.
Q4: In the payment cycle, which step occurs immediately after claim submission?
• A. Payment posting
• B. Claim adjudication. [CORRECT]
• C. Payment reconciliation
• D. Appeals process
Correct Answer: B Rationale: Claim adjudication (B) is the payer's review process that occurs
immediately after submission. Payment posting (A) and reconciliation (C) occur after
adjudication. Appeals (D) follow if claims are denied or underpaid.
Q5: Which term describes the document sent by a payer to a provider explaining how a claim
was processed, including payments, adjustments, and denials?
• A. Electronic Funds Transfer (EFT)
• B. Explanation of Benefits (EOB). [CORRECT]
• C. Prior Authorization
• D. Fee Schedule
Correct Answer: B Rationale: The EOB (B) explains claim processing details to providers and
patients. EFT (A) refers to electronic payment transfer. Prior authorization (C) is pre-approval for
services. A fee schedule (D) lists contracted reimbursement rates.
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Q6: A payment specialist notices that a commercial payer's remittance advice indicates a
"contractual adjustment" of $500. This adjustment represents:
• A. An underpayment requiring appeal
• B. The difference between billed charges and the contracted allowed amount.
[CORRECT]
• C. A duplicate payment correction
• D. A patient responsibility amount
Correct Answer: B Rationale: Contractual adjustments (B) represent the write-off of charges
exceeding the contracted allowed amount per payer agreements. This is not an underpayment
(A), duplicate correction (C), or patient responsibility (D).
Q7: Which payer type typically offers both in-network and out-of-network benefits, with higher
cost-sharing for out-of-network services?
• A. Health Maintenance Organization (HMO)
• B. Preferred Provider Organization (PPO). [CORRECT]
• C. Exclusive Provider Organization (EPO)
• D. Indemnity plan
Correct Answer: B Rationale: PPOs (B) offer flexibility with both in-network and out-of-
network coverage, though out-of-network costs more. HMOs (A) and EPOs (C) typically don't
cover out-of-network care. Indemnity plans (D) don't have networks.
Q8: In healthcare payment terminology, "remittance" refers to:
• A. The initial claim submission to a payer
• B. The payment and adjustment information sent from payer to provider. [CORRECT]
• C. The patient's copayment at time of service
• D. The process of verifying patient eligibility
Correct Answer: B Rationale: Remittance (B) is the payment and adjustment information sent
by payers to providers, typically via ERA/EOB. It is not claim submission (A), patient copays
(C), or eligibility verification (D).
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Q9: Which government program provides healthcare coverage for active duty military personnel,
retirees, and their families?
• A. Medicare
• B. Medicaid
• C. TRICARE. [CORRECT]
• D. Veterans Health Administration (VHA)
Correct Answer: C Rationale: TRICARE (C) serves active duty military, retirees, and families.
Medicare (A) covers elderly/disabled. Medicaid (B) covers low-income populations. VHA (D)
serves veterans through VA facilities.
Q10: A payment specialist is reviewing the payment cycle workflow. Which sequence correctly
represents the standard payment cycle?
• A. Claim submission → Payment posting → Adjudication → Reconciliation
• B. Claim submission → Adjudication → Payment/denial → Reconciliation → Appeal (if
needed). [CORRECT]
• C. Adjudication → Claim submission → Payment posting → Reconciliation
• D. Reconciliation → Claim submission → Adjudication → Payment posting
Correct Answer: B Rationale: The standard cycle (B) is: submit claim, payer adjudicates,
payment or denial occurs, reconciliation follows, and appeals happen if necessary. Other
sequences misorder critical steps.
Q11: Which transaction set is used to electronically submit healthcare claims to payers?
• A. 835
• B. 837. [CORRECT]
• C. 270/271
• D. 276/277
Correct Answer: B Rationale: The 837 transaction (B) is the standard for electronic claim
submission. The 835 (A) is for remittance advice. 270/271 (C) handles eligibility. 276/277 (D)
manages claim status inquiry/response.
