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RPB390
Resolute Professional Billing Expected Reimbursement Contracts
| Question | Answer |
|---|---|
| Your reimbursement contract build calculates you will be able to receive $64.00 from the payer and patient. | Expected Reimbursement Amount |
| A charge post with a price of $77.00. This is the _________. | Billed Amount |
| The payer's calculation matches your contract and the payer agrees that you should be able to collect $64. | Allowed Amount |
| The difference between the price of the charge and what the payer agrees that you should be able to collect is $13.00. This is the ________________. | Not Allowed Amount |
| When importing Fee Schedules, you must create a text file before loading the data into Epic. | True |
| Professional Billing underpayments are worked from which type of workqueues: | Follow-up workqueues |
| 60432‐ Mult Px ‐ No Automation ‐ Reimbursement Contract: | The system doesn't automatically apply modifiers or adjust expected reimbursement based on multiple procedure logic, but expected reimbursement is adjusted if a user manually enters a modifier. |
| Your payer will reimburse you 85% of the Medicare Fee Schedule for services performed in the Family Medicine Department. Which payment mechanism should be used on the service components tab? | Percent of Fee Schedule |
| What type of record is used to calculate the expected reimbursement amount for case rate contract terms? | Extension |
| (T/F) The Applies to tab of a reimbursement contract is contact-specific. | False |
| Which environment is used to test out your reimbursement contracts after being moved from POC? | TST |
| (T/F) Reimbursement Contracts affect the billing amount/price. | False |
| This amount is written off and is the difference between the allowed amount and the billed amount. | Not allowed amount |
| The PRICE of a charge sent out on the claim to the payer. | Billed amount |
| The amount built in your reimbursement contract that you EXPECT to collect. | Expected reimbursement amount |
| Actual COLLECTABLE amount on the EOB from a payer. | Allowed Amount |
| The DIFFERENCE between the allowed amount and the billed amount that is WRITTEN OFF | Not allowed amount |
| (T/F) When a contracted payer pays a claim, the allowed amount from the reimbursement contract automatically populates the Allowed field for manual payment posting. | True |
| Test build before sending to PRD. | TST, or Test |
| Live environment | PRD, or Production |
| Troubleshooting. Produced as a nightly copy of PRD. Also used to test build on real patient data befor it's migrated to PRD. | SUP, or Support |
| Used for running reports that require production-based data. Great for contract modeling. Can be refreshed. | PJX, or Projects |
| In order for a contractual adjustment to occur, a charge needs to have both ___ and ____ | Price & Expected reimbursement amount. |
| In which environment do end users perform their daily workflows? Choose ONLY one: | PRD |
| (T/F) All initial build is typically completed in the TST environment. | False |
| What records created from Registration are needed to test Reimbursement contract build? | Patient,Guarantor Account and Coverage |
| In order to report on underpayments for the past year, which report would you use? | Reimbursement Underpayment Detail Report |
| From which type of workqueue are underpayments worked? | Follow-up Workqueues |
| Which of the following correctly defines contract modeling as it is performed in Epic? | Taking changes to the contract or pricing data and comparing it against historical claims data already in the system. |
| (T/F) You can only model contract changes against claims from the past year. | False. You can model against historical claims that exist in the environment in which you are running the model. |
| (T/F) Making a copy of a contract for modeling will make a copy of the contract record as well as a copy of all records inside that contract (like components and fee schedule). | False |
| (T/F) To import records into Epic you can start with a blank spreadsheet as the column and row configuration does not matter | False |
| What is the import spec used to import Fee Schedules in Chronicles? | FSC, 1100 |
| (T/F) A charge session can ONLY qualify for one line of the Percentage Adjustments table. | False |
| Which of the following are examples of rules that can be used in the MPPR table? | Diagnostic Imaging, Multiple Cardiovascular Procedures, Multiple Ophthalmology Procedures and Endoscopic Rule |
| (T/F) Configuration in your reimbursement contract can re‐order charges on a claim set to CMS standards. | True |
| When using the Submit for Re‐eval option in Contract Maintenance, when do any selected actions occur? | During a scheduled batch job |
| (T/F) On the Service Components tab of a reimbursement contract, more specific contract lines should be listed higher in priority than more general contract lines. | True |
| Which of the following payment mechanisms will calculate expected reimbursement at a percentage of the original charged amount? | Percent of BIlled |
| On which tab of the reimbursement contract do you specify payment mechanisms for calculating expected reimbursement? | Service Components |
| When a charge qualifies for multiple reimbursement contracts, which setting helps determine | Reimbursement Contract Precedence |
| On which tab of the reimbursement contract do you configure when the write‐off is posted? | General Settings |
| When determining whether a reimbursement contract should be applied to any charge, the system compares the information on the _____ to the_____ | Applies To tab and characteristics of the specific charge session |
| The price of a charge sent out on the claim to the payer. | Billed amount |
| The amount built in your reimbursement contract that youexpect to collect. | Expected reimbursement amount |
| In order to report on underpayments for the past year, which report world you use? | Reimbursement Underpayment Detail Report |
| From which type of workqueue are underpayments worked? | Follow-Up Workqueues |
| Estimates are available for both prospective patients and existing patients looking for a future service | Pre‐service |
| The amount built in your reimbursement contract that you expect to collect. | Expected reimbursement amount |
| Actual collectable amount on the EOB from a payer. | Allowed amount |
| The difference between the allowed amount and the billed amount that is written off. | Not allowed amount |
| Epic’s front‐end user interface, accessed on the client. It’s what most users think of as “Epic” and what you used in your Fundamentals class. End users log in to system to complete their workflows and do their jobs. | Hyperspace |
| Estimates allow you to collect as much of the patient portion up‐front as possible In order for your estimates to be accurate, your organization needs accurate configuration in many areas,including pricing, benefits collection, real‐time‐eligibility, and | Time of service |
| The old Hyperspace that is being phased out. As of Epic’s May 2022 release, all end‐user facing activities are available in the new, web‐based Hyperspace. | Classic |
| Epic’s database management system, often referred to as “the database.” All the data that users access in Hyperspace actually lives in heres. you requesting data from this system. they are saving data to this system. | Chronicles |
| Tab to plan your build and maintenance work. Suggested tracking includes when you start negotiations per contract and how long updates tend to take based on complexity. | Annual calendar ‐ Simple |
| Text‐based, back‐end interface with Chronicles data, used solely by administrators for creating, editing, and analyzing records. Text runs directly on the server that hosts Chronicles, and you connect to it via a terminal emulator | Text |
| Tab for tracking contact information of key players you'll work with, including payer contacts. | Key Players |
| the adjustment posted during claims processing offsets the difference between the reimbursement amount calculated at charge entry and the reimbursement amount calculated during claims processing | Both Claims and Charge Entry |
| Tab to plan detailed build and maintenance work. You can plan out rows and notes for future contract build. | Annual Calendar ‐ Detailed |
| Tab uses groups to identify procedures included in the reimbursement contract. Those procedures are associated with a payment mechanism which is configured to calculate the allowed amount. | Service Components |
| The system will write‐off the difference only when the insurance payment is posted. | Auto write‐off |
| Your organization can determine if the billing or service provider is referenced when using a reimbursement contract with a Provider eligibility requirement | Pricing & Reimb Provider |
| Values on the ____________tab reference Contract Grading and Builder Grading scales, both of which are found on the next tab in the spreadsheet. | Contract Matrix |
| On which tab of the reimbursement contract do you specify payment mechanisms for calculating expected reimbursement | Service Components |
| A planning tool available on Galaxy. You'll gather information about your existing contracts, and the tool will help you prioritize the build required and timelines based on your available resources. | Resolute Professional Billing Contract Tracker |
| On which tab of the reimbursement contract do you configure when the write‐off is posted | General Settings |
| T/F The information configured on the Applies To tab is contact‐specific | False |
| When a charge qualifies for multiple reimbursement contracts, which setting helps determinewhich contract is considered highest priority | Reimbursement Contract Precedence |
| Which of the following payment mechanisms will calculate expected reimbursement at a percentage of the original charged amount | Percent of Billed |
| True or False: On the Service Components tab of a reimbursement contract, more specific contract lines should be listed higher in priority than more general contract lines | True |
| This tab allows you to refine the expected reimbursement based on additional criteria | Further Reductions |
| If a claim qualifies for your multiple procedures logic, the system automatically adds or removes the modifier and adjusts expected reimbursement according to the logic. | 60430‐ Standard Multiple Procedures Logic |
| If a claim qualifies for your multiple procedures logic, the system automatically adjusts expected reimbursement but doesn't add or remove modifiers according to the logic. | 60431‐ Mult Px ‐ Use Rule, Suppress Modifier |
| True or False: A charge session can ONLY qualify for one line of the Percentage Adjustments table. | False |
| Queue for re‐evaluation of expected reimbursement | This mode updates allowed amounts and allows for corrective write‐offs of the net difference to be posted |
| When using the Submit for Re‐eval option in Contract Maintenance, when do any selected actions occur? | When a batch job using template 1404 runs |
| True or False: As long as the contract is currently open, the re‐evaluation batch job will successfully complete | False |
| The system doesn't automatically apply modifiers or adjust expected reimbursement based on multiple procedure logic, but expected reimbursement is adjusted if a user manually enters a modifier | 60432‐ Mult Px ‐ No Automation |
| the method the system uses to sort charges on a claim | Override CDF‐ level claim sorting |
| This table generally allows you to follow Medicare's guidelines when it comes to payment of select services. | Multiple Procedure Payment Reduction |
| CMS rules are applied in ranking grouped charges by endoscopic family. The highest‐ranked charge within an endoscopic family is assigned an expected reimbursement equal to 100% of the allowed amount calculated by the lines of the contract. | Endoscopic Rule |
| Similar to the endoscopic rule, the diagnostic imaging rule uses CMS rules to group and rank procedures. Using CMS standards, the system appropriately determines expected allowed amounts based off of technical components. | Diagnostic Imaging Rule |
| This rule works very similarly to that of the Cardiovascular rule discussed earlier in the lesson except the MPI of the procedure is set to 7 and the TC is reimbursed at 80%. | Ophthalmology Rule |
| For procedures labeled with an MPI value of 5. This rule will use a feeschedule that includes the reduced reimbursement for subsequent therapy services after the first procedure | Therapy Rule |
| Reporting Workbench Report run by a user in real‐time out of Hyperspace. | Contract Variance Report |
| The report provides a listing of all charges with a service date in a given date range and displays data regarding if reimbursement was made at the appropriate rate. This report is a Clarity report and is best used for long term trending data | Reimbursement Underpayment Detail Report |
| Which of the following correctly/completely defines contract modeling as it is performed in Epic? | Taking changes to the contract or pricing data and comparing it against historical claims data already in the system |
| True or False: Making a copy of a contract for modeling will make a copy of the contract record as well as a copy of all records inside that contract ﴾like components and fee schedules﴿. | False |
| This is the environment that you use to complete your initial build by creating or editing records. Build from this environment is sent to TST using the Data Courier tool. | POC or Proof of Concept |
| a tool that allows you to move information between environments and maintain referential integrity between multiple environments. | Data Courier |
| the charge is posted to the guarantor account, you can then view the expected reimbursement amount of the charge in ________________________. | PB Transaction Inquiry |
| Allow you to provide an up‐front look at the patient‐portion that will be owed by a patient for services you provide | Estimate Integration |
| Aa tool that automates many tasks in the system (like claims and statement processing). The batch scheduler is also used to schedule when Re‐evaluation will occur. This is a system‐intensive process that could take a while to complete. | Batch Scheduler |
| The system groups together charges listed in the claims queue with the same encounter information and runs them through the CDF. Clean claims stay in the run and submitted. | Claim Run |
| When a charge qualifies for multiple reimbursement contracts, which setting helps determine which contract is considered highest priority | Reimbursement Contract Maintenance |
| True or false: On the Service Components tab of a reimbursement contract, more specific contract lines should be listed higher in priority than more general contract lines. | True |
| True or false: A charge session can ONLY qualify for one line of the Percentage Adjustments table. | False |
| True or false: To import records into Epic you can start with a blank spreadsheet as the column and row configuration does not matter. | False |
| When using the Submit for Re-eval option in Contract Maintenance, when do any selected actions occur. | During a scheduled batch job |
| defines which attributes of a charge session are of the highest priority when determining which contract should be used. You must either enter all ten in an order of precedence that works for your organization or leave this setting blank. | reimbursement contract precedence |
| On which tab of the reimbursement contract do you configure when the write‐off is posted | General Settings |
| Some payers will reimburse a covers multiple charges on a single invoice | flat rate |
| On which tab of the reimbursement contract do you specify payment mechanisms for calculating expected reimbursement. | Service Components |
| Which of the following payment mechanisms will calculate expected reimbursement at a percentage of the original charged amount? | Percent of Billed |
| True or False: On the Service Components tab of a reimbursement contract, more specific contract lines should be listed higher in priority than more general contract lines. | True |
Created by:
Bridgette108
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