CRCR Part 4 Flashcards

Financial Transactions

• Electronic Funds Transfer (EFT) is the quickest way to move money, allowing same-day transfers between banks.
• Electronic Remittance Advice (ERA) is a standardized format for sending third-party payment details to healthcare providers.

ERA Levels

• ERA Level 1: Electronic receipt of 835 data only, printed and processed like a paper remittance.
• ERA Level 2: Electronic receipt and data entry, viewed in a terminal.
• ERA Level 3: Electronic receipt, data entry, reconciliation, posting, and closing of 835 data.
• ERA Level 4: Total automation, including receipt, data entry, payment posting, and adjustment processing.

Credit Balances and Reporting

• Credit balances occur when payments and contractual adjustments exceed total charges.
• CMS-838 is the Medicare form used to report credit-balance overpayment accounts quarterly.

Denials

• Technical denials: Missing or incomplete claim information.
• Clinical denials: Associated with the care or service provided.
• Underpayment denials: Health plan pays less than the agreed contract amount.
• Pre-service denials: Examples include not obtaining pre-auth, incorrect data entry.
• Time-of-service denials: Examples include new technology used without determining coverage, incorrect coding.
• Post-service denials: Examples include late charges, duplicate claims, untimely filing.

Audits and Appeals

• Recovery Audit Contractors (RAC) protect Medicare from fraudulent and abusive billing.
• Beneficiary appeal type: Filed by the Medicare beneficiary dissatisfied with the government's claim determination.
• Provider appeal type: Filed by the provider, with options for hearings or filing with the Provider Reimbursement Review Board.

Liens

• Medicare Waiver of Liability: Medicare is liable for paying the claim if the beneficiary or provider didn't know the services were not covered.
• Liens: A claim against real or personal property to secure payment of a debt or performance.
• Agreement liens: Filed under the Uniform Commercial Code (UCC) to protect a security interest.
• Judicial liens: Result from a creditor's inability to collect via reasonable means.
• Statute liens: Four common types, including employee's lien, landlord's lien, materialman's lien, and tax lien.

Test your knowledge with these flashcards from CRCR Part 4. The terms focus on key concepts like General Ledger Cash and Electronic Funds Transfer. Perfect for reinforcing your understanding of essential financial transactions.