HFMA CRCR Master Practice Exam 100
Questions and Answers for Certified Revenue
Cycle Representative Preparation.
Domain 1: The Patient Access, the Registration & the Financial Clearance
1. (SATA) During the primary registration process, the Patient Access representative must
accurately capture specific data elements to ensure clean claim submission. Which of the
following data elements are critical for establishing patient identity and insurance
verification?
A. The patient’s complete legal name and date of birth.
B. The insurance policy ID number and group number.
C. The name of the admitting physician’s medical school.
D. The Coordination of Benefits (COB) order of priority.
2. A patient presents for a scheduled surgery. The registration system indicates the patient has
primary insurance with Blue Cross and secondary insurance with Medicare. Which specific
regulation requires the registration team to identify Medicare as the Secondary Payer (MSP)?
A. The Two-Midnight Rule.
B. The Medicare Secondary Payer Act.
C. The Emergency Medical Treatment and Labor Act (EMTALA).
D. The Health Insurance Portability and Accountability Act (HIPAA).
3. (True/False) A minor discrepancy in the patient’s demographic data, such as a transposed
digit in the date of birth, will not impact the claim adjudication process as long as the medical
record number is correct.
A. True
B. False
,4. When a patient has coverage under two commercial insurance plans, the "Birthday Rule" is
a standard methodology used to determine which of the following?
A. Which parent’s insurance covers the child.
B. The order of coordination of benefits (COB) for a dependent child.
C. The effective date of the insurance policy.
D. The timely filing limit for the claim.
5. Failure to verify the specific terms of a patient's insurance eligibility prior to service
typically results in which of the following revenue cycle outcomes?
A. An increase in the hospital’s Case Mix Index (CMI).
B. A higher probability of claim denial for non-coverage.
C. A reduction in the Medicare Wage Index.
D. An automatic waiver of the patient’s deductible.
6. A patient is scheduled for a total knee arthroplasty (TKA). The hospital’s claim scrubber
validates the diagnosis code against the Medicare Local Coverage Determination (LCD). If the
LCD requires a specific diagnosis for medical necessity, and the documentation does not
support it, what is the immediate financial risk?
A. The claim will be paid, but audited later.
B. The claim will be denied as "not medically necessary."
C. The patient will automatically qualify for Medicaid.
D. The DRG relative weight will be reduced.
7. Which specific Medicare tool must the Patient Access staff query to verify if a specific
CPT/HCPCS code is covered under an LCD for a specific diagnosis?
A. The Medicare Physician Fee Schedule (MPFS).
B. The CMS LCD and NCD repository lookup.
C. The Outpatient Prospective Payment System (OPPS) file.
,D. The Inpatient Only List.
8. (SATA) A surgeon schedules a total knee arthroplasty. To ensure compliance with the LCD
medical necessity requirements, the registration staff must verify which of the following?
A. That the specific ICD-10-CM diagnosis code is listed on the LCD coverage list.
B. That the patient has signed an Advanced Beneficiary Notice (ABN) for all covered services.
C. That the required clinical criteria (e.g., failed conservative treatment) are met.
D. That the procedure is performed in an Ambulatory Surgical Center (ASC).
9. A medical necessity screen fails for a scheduled outpatient service. The LCD indicates the
diagnosis provided is not covered. Which specific form must be issued to the Medicare
patient to shift financial liability to the beneficiary?
A. The HIPAA Notice of Privacy Practices.
B. The Advance Beneficiary Notice of Noncoverage (ABN).
C. The Medicare Summary Notice (MSN).
D. The Explanation of Benefits (EOB).
10. When a Medicare patient refuses to sign an ABN for a service that is likely to be denied
due to lack of medical necessity, what is the correct course of action for the hospital?
A. Cancel the procedure and discharge the patient.
B. Provide the service and bill Medicare; if denied, the hospital cannot bill the patient.
C. Provide the service and bill the patient immediately without billing Medicare.
D. Appeal the LCD directly to the MAC.
11. A patient presents for an outpatient service. The insurance verification indicates the
patient has a $500 deductible and 20% co-insurance. The estimated charge for the service is
$1,000. If the allowed amount is $800, what is the correct pre-service estimate the hospital
should request from the patient?
, A. $500 (Deductible only).
B. $660 ($500 Deductible + $160 Co-insurance).
C. $800 (Total allowed amount).
D. $200 (20% of $1,000).
12. (Calculation) A patient has a commercial insurance plan with a $1,000 deductible and a
$50 copay. The patient has already paid $750 toward the deductible this year. The hospital’s
allowed amount for today’s procedure is $500. How much should the Patient Access staff
collect from the patient at the time of service?
A. $300
B. $250
C. $550
D. $500
13. Which specific metric measures the effectiveness of the patient access department in
collecting the patient’s estimated financial responsibility prior to the service?
A. Net Days in A/R.
B. Pre-service Point of Service (POS) Cash Collections.
C. Clean Claim Rate.
D. Denial Rate.
14. When calculating a patient’s out-of-pocket cost for an "Out-of-Network" provider, which
factor most significantly increases the patient's liability?
A. The absence of a contracted rate (Allowed Amount).
B. The timely filing limit.
C. The Coordination of Benefits.
D. The medical necessity screen.
Questions and Answers for Certified Revenue
Cycle Representative Preparation.
Domain 1: The Patient Access, the Registration & the Financial Clearance
1. (SATA) During the primary registration process, the Patient Access representative must
accurately capture specific data elements to ensure clean claim submission. Which of the
following data elements are critical for establishing patient identity and insurance
verification?
A. The patient’s complete legal name and date of birth.
B. The insurance policy ID number and group number.
C. The name of the admitting physician’s medical school.
D. The Coordination of Benefits (COB) order of priority.
2. A patient presents for a scheduled surgery. The registration system indicates the patient has
primary insurance with Blue Cross and secondary insurance with Medicare. Which specific
regulation requires the registration team to identify Medicare as the Secondary Payer (MSP)?
A. The Two-Midnight Rule.
B. The Medicare Secondary Payer Act.
C. The Emergency Medical Treatment and Labor Act (EMTALA).
D. The Health Insurance Portability and Accountability Act (HIPAA).
3. (True/False) A minor discrepancy in the patient’s demographic data, such as a transposed
digit in the date of birth, will not impact the claim adjudication process as long as the medical
record number is correct.
A. True
B. False
,4. When a patient has coverage under two commercial insurance plans, the "Birthday Rule" is
a standard methodology used to determine which of the following?
A. Which parent’s insurance covers the child.
B. The order of coordination of benefits (COB) for a dependent child.
C. The effective date of the insurance policy.
D. The timely filing limit for the claim.
5. Failure to verify the specific terms of a patient's insurance eligibility prior to service
typically results in which of the following revenue cycle outcomes?
A. An increase in the hospital’s Case Mix Index (CMI).
B. A higher probability of claim denial for non-coverage.
C. A reduction in the Medicare Wage Index.
D. An automatic waiver of the patient’s deductible.
6. A patient is scheduled for a total knee arthroplasty (TKA). The hospital’s claim scrubber
validates the diagnosis code against the Medicare Local Coverage Determination (LCD). If the
LCD requires a specific diagnosis for medical necessity, and the documentation does not
support it, what is the immediate financial risk?
A. The claim will be paid, but audited later.
B. The claim will be denied as "not medically necessary."
C. The patient will automatically qualify for Medicaid.
D. The DRG relative weight will be reduced.
7. Which specific Medicare tool must the Patient Access staff query to verify if a specific
CPT/HCPCS code is covered under an LCD for a specific diagnosis?
A. The Medicare Physician Fee Schedule (MPFS).
B. The CMS LCD and NCD repository lookup.
C. The Outpatient Prospective Payment System (OPPS) file.
,D. The Inpatient Only List.
8. (SATA) A surgeon schedules a total knee arthroplasty. To ensure compliance with the LCD
medical necessity requirements, the registration staff must verify which of the following?
A. That the specific ICD-10-CM diagnosis code is listed on the LCD coverage list.
B. That the patient has signed an Advanced Beneficiary Notice (ABN) for all covered services.
C. That the required clinical criteria (e.g., failed conservative treatment) are met.
D. That the procedure is performed in an Ambulatory Surgical Center (ASC).
9. A medical necessity screen fails for a scheduled outpatient service. The LCD indicates the
diagnosis provided is not covered. Which specific form must be issued to the Medicare
patient to shift financial liability to the beneficiary?
A. The HIPAA Notice of Privacy Practices.
B. The Advance Beneficiary Notice of Noncoverage (ABN).
C. The Medicare Summary Notice (MSN).
D. The Explanation of Benefits (EOB).
10. When a Medicare patient refuses to sign an ABN for a service that is likely to be denied
due to lack of medical necessity, what is the correct course of action for the hospital?
A. Cancel the procedure and discharge the patient.
B. Provide the service and bill Medicare; if denied, the hospital cannot bill the patient.
C. Provide the service and bill the patient immediately without billing Medicare.
D. Appeal the LCD directly to the MAC.
11. A patient presents for an outpatient service. The insurance verification indicates the
patient has a $500 deductible and 20% co-insurance. The estimated charge for the service is
$1,000. If the allowed amount is $800, what is the correct pre-service estimate the hospital
should request from the patient?
, A. $500 (Deductible only).
B. $660 ($500 Deductible + $160 Co-insurance).
C. $800 (Total allowed amount).
D. $200 (20% of $1,000).
12. (Calculation) A patient has a commercial insurance plan with a $1,000 deductible and a
$50 copay. The patient has already paid $750 toward the deductible this year. The hospital’s
allowed amount for today’s procedure is $500. How much should the Patient Access staff
collect from the patient at the time of service?
A. $300
B. $250
C. $550
D. $500
13. Which specific metric measures the effectiveness of the patient access department in
collecting the patient’s estimated financial responsibility prior to the service?
A. Net Days in A/R.
B. Pre-service Point of Service (POS) Cash Collections.
C. Clean Claim Rate.
D. Denial Rate.
14. When calculating a patient’s out-of-pocket cost for an "Out-of-Network" provider, which
factor most significantly increases the patient's liability?
A. The absence of a contracted rate (Allowed Amount).
B. The timely filing limit.
C. The Coordination of Benefits.
D. The medical necessity screen.
