HFMA Exam Latest Update Questions Answers Grade

Certified Specialist Payment Rep (HFMA) Exam (Latest Update 2025 / 2026) Questions & Answers | Grade A | 100% Correct (Verified Solutions)

Question:

The three technique application methods used for utilization management

include the following:

Answer:

-Prospective UM Techniques - UM reviews the need for inpatient care or other care before admission. The health plan determines, at this point, whether it will pay for the service

-Concurrent UM Techniques - Authorization required during a patient's inpatient admission

-Retrospective UM Techniques - Authorization reviews to determine medical necessity of a service, treatment or procedure

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Question:

Catastrophic Case Management

Answer:

used to manage diseases associated with very high costs of care.

Question:

PCMH model

Answer:

a term used to describe a model of care in which primary care services are delivered to families in an accessible, continuous, comprehensive, and integrated fashion.

Question:

Electronic Data Interchange (EDI)

Answer:

the exchange of computerized data in a standardized format allows both healthcare providers and payers to exchange common information required to improve the quality of care while measurably reducing the cost of that care.

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Question:

The specific roles and responsibility of each level within the small physician

practice managed care infrastructure included the following:

Answer:

-Practice Manager - Oversee all operational aspects of the practice, including managed care contracting.

-Physician Leader(s) - Provide input to the practice manager regarding expected/target reimbursement rates and help identify any specific aspects of the contract that may be difficult to administer.

-Registration Staff - Assist with eligibility verification and accurate entry of patient insurance information into the practice management or billing system.

-Clinical Staff - Must be familiar with payer requirements for appropriate documentation of medical necessity and protocols for pre-authorizations.

-Billing Staff - Responsible for submitting claims to the appropriate payers and managing payments received from payers and patients.

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Question:

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

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