AAPC CPB EXAMINERS 2027 ANSWERS AND
QUESTIONS SET A+
✔✔Carl has enrolled in a healthcare insurance plan that allows him to choose to have
services provided within the BCBS network or outside of the network what type of plan
best describes Carl's coverage - ✔✔POS
✔✔What is the limit called what payrs allow to submit a claim or appeal? - ✔✔Timely
filing
✔✔Jerod is employed with the US IRS and has enrolled in the BCBS healthcare
insurance offered through his employer, what is the name of the BCBS insurance
program offered by the federal government? - ✔✔FEP(Federal Employee Program)
✔✔What may be appealed? - ✔✔A denied claim
✔✔A savings account that allows individuals to save pre tax dollars to reimburse for
healthcare expenses is known as an: - ✔✔FSA and HSA
✔✔What modifiers will appropriately bypass the NCCI bundling edits? - ✔✔25, 58
✔✔Tony's BCBS insurance policy states that he must seek healthcare services only
from providers that are part of a specific network what type of BCBS does Tony have? -
✔✔HMO
✔✔BCBS identifies the individual who pays for healthcare insurance coverage as the: -
✔✔subscriber
✔✔What can be done in the practice to ensure liability denials will not be received? -
✔✔Perform thorough intake on patients that present with injuries
,✔✔BCBS identifies the individual who is eligible for covered services as the: -
✔✔Member
✔✔Under what federal act must insurance companies implement effective appeals
processes? - ✔✔The patient protection and affordable care act
✔✔BCBS received a claim on 4/15/14 for services performed on 3/15/13 the claim
would be denied because: - ✔✔The claim was filed after the timely filing limit
✔✔Submitting a secondary claim without a primary insurance EOB is what kind of
issue? - ✔✔COB
✔✔The process of reviewing and validating professional qualifications of healthcare
providers applying to participate with an organization is known as: - ✔✔Credentialing
✔✔An initial denial is received in the office from Aetna, the denial is investigated and
the office considers that the payment was not according to their contract. According to
Aenta's policy what must the biller do? - ✔✔Resubmit a reconsideration
✔✔Participating providers agree to: - ✔✔Accept the fee schedules determined by the
insurance company
✔✔What is "Medically necessary" - ✔✔Services appropriate to the evaluation and
treatment of a disease condition illness or injury and consistent with the applicable
standard of care
✔✔What information can be found on an EOB - ✔✔
✔✔What rejections/Denials are mostly preventable with good front office policy? -
✔✔Incorrect patient information, eligibility expiration, and liability denials
✔✔Timely filing requirements are determined by: - ✔✔The payer
✔✔The best practice to prevent a non-covered service denial would be to: -
✔✔Determine if the procedure is covered prior to providing the service
✔✔A denial is received in the office indicating that a service that was billed is denied
due to bundling issues. The medical record is obtained and, upon review, it is
documented that the second procedure is a staged procedure that was planned at the
time of the initial procedure. When the claim is reviewed, no modifier was attached to
the codes on the claim. What should be done to resolve the claim? - ✔✔Add modifier 58
to the procedure and follow the payer's guidelines for appeals
,✔✔What type of denial is more likely to happen when the patient is insured through an
HMO? - ✔✔No referral
✔✔Best practice to prevent receiving a denial due to coverage termination would be to:
- ✔✔Verify coverage prior to the patient's scheduled appointment.
✔✔What is the first step in the majority of denial cases, that you should take? - ✔✔Call
the insurance company and find out why the claim is being denied.
✔✔The liaison between BCBS and the contracted provider community is known as
what? - ✔✔The insurance representative. Also known as the provider representative or
the provider network consultant.
✔✔In what box on the CMS-1500 form does a PA number get placed? - ✔✔Box 23
✔✔A health insurance plan that reimburses for healthcare services provided to
members based on providers bills submitted after the services are rendered is known
as: - ✔✔Traditional insurance. Also known as Fee-for-service, or an indemnity plan.
✔✔What is the difference between non-covered services and not medically necessary
services? - ✔✔Non-covered services are pre-determined to not be re-reimbursable by
the insurance while not-medically necessary services have been found to not be
necessary for the evaluation and treatment of an individuals disease, condition, illness,
or injury.
✔✔When a patient presents for their appointment, insurance coverage should be
verified and: - ✔✔A copy should be made of both the front and back of the member's
insurance card.
✔✔For which denial is it acceptable to balance bill the patient? - ✔✔Non-covered
service
✔✔BCBS offers which type of Medicare plan? - ✔✔A medicare advantage plan (part C)
✔✔A participating provider of BCBS sees a patient in the ER. The charges equal $500.
The patient has a $1000 deductible of which none has been met, and a $75 ER copay,
How much should be collected from the patient for this service? - ✔✔$75
✔✔What is a copay? - ✔✔A fixed amount of money that you will pay for an office visit
*same day*.
✔✔What is a deductable? - ✔✔The amount of money you need to pay for services
before insurance will pay anything.
, ✔✔What is Co-insurance? - ✔✔The amount of money you will pay for services after the
deductible is met but *before* you have reached your maximum out of pocket amount.
✔✔What is Out-of-pocket? - ✔✔The amount of money you need to pay out of pocket
*before* insurance will pay at 100%.
✔✔What are the 4 parts of Medicare? - ✔✔A,B,C,D
✔✔What does Medicare A cover? - ✔✔Hospital services
✔✔What does Medicare B cover? - ✔✔Out-patient services
✔✔What is Medicare C? - ✔✔This is a Medicare replacement plan for A+B offered by
private companies that are contracted with Medicare. AKA a medicare advantage plan.
✔✔What is Medicare D? - ✔✔Coverage for prescription medicine
✔✔A patient receiving inpatient care in a critical access hospital would be covered
under which part of Medicare? - ✔✔Part A
✔✔For services such as screening for depression, bone mass measurements, and
glaucoma screenings, what does Medicate consider these services to be? -
✔✔Preventative
✔✔To determine the Medicare coverage and payment policy for a service or procedure,
which resources will indicate if a service or procedure is payable, non-covered, or
bundled into another service? - ✔✔Status codes
✔✔Medigap policies must conform to minimum standards identified as federal and state
laws and clearly be identified as: - ✔✔Medicare supplemental insurance
✔✔Allen who is a non-par provide who doesn't accept assignment performs an
appendectomy on a 67 year old Medicare patient. The physician's UCR for the surgery
is $1500. Medicare's approved fee for this procedure is $1100. What is the charge that
this non-par provider can charge to this Medicare patient? - ✔✔$1201.75
✔✔A Medicare patient is seen by a participating provider. A claim is sent for $123 and
an EOMB is received that states the approved amount is $100. If the patient has met
their deductible, what should the reimbursement on this claim be from Medicare? -
✔✔$80
QUESTIONS SET A+
✔✔Carl has enrolled in a healthcare insurance plan that allows him to choose to have
services provided within the BCBS network or outside of the network what type of plan
best describes Carl's coverage - ✔✔POS
✔✔What is the limit called what payrs allow to submit a claim or appeal? - ✔✔Timely
filing
✔✔Jerod is employed with the US IRS and has enrolled in the BCBS healthcare
insurance offered through his employer, what is the name of the BCBS insurance
program offered by the federal government? - ✔✔FEP(Federal Employee Program)
✔✔What may be appealed? - ✔✔A denied claim
✔✔A savings account that allows individuals to save pre tax dollars to reimburse for
healthcare expenses is known as an: - ✔✔FSA and HSA
✔✔What modifiers will appropriately bypass the NCCI bundling edits? - ✔✔25, 58
✔✔Tony's BCBS insurance policy states that he must seek healthcare services only
from providers that are part of a specific network what type of BCBS does Tony have? -
✔✔HMO
✔✔BCBS identifies the individual who pays for healthcare insurance coverage as the: -
✔✔subscriber
✔✔What can be done in the practice to ensure liability denials will not be received? -
✔✔Perform thorough intake on patients that present with injuries
,✔✔BCBS identifies the individual who is eligible for covered services as the: -
✔✔Member
✔✔Under what federal act must insurance companies implement effective appeals
processes? - ✔✔The patient protection and affordable care act
✔✔BCBS received a claim on 4/15/14 for services performed on 3/15/13 the claim
would be denied because: - ✔✔The claim was filed after the timely filing limit
✔✔Submitting a secondary claim without a primary insurance EOB is what kind of
issue? - ✔✔COB
✔✔The process of reviewing and validating professional qualifications of healthcare
providers applying to participate with an organization is known as: - ✔✔Credentialing
✔✔An initial denial is received in the office from Aetna, the denial is investigated and
the office considers that the payment was not according to their contract. According to
Aenta's policy what must the biller do? - ✔✔Resubmit a reconsideration
✔✔Participating providers agree to: - ✔✔Accept the fee schedules determined by the
insurance company
✔✔What is "Medically necessary" - ✔✔Services appropriate to the evaluation and
treatment of a disease condition illness or injury and consistent with the applicable
standard of care
✔✔What information can be found on an EOB - ✔✔
✔✔What rejections/Denials are mostly preventable with good front office policy? -
✔✔Incorrect patient information, eligibility expiration, and liability denials
✔✔Timely filing requirements are determined by: - ✔✔The payer
✔✔The best practice to prevent a non-covered service denial would be to: -
✔✔Determine if the procedure is covered prior to providing the service
✔✔A denial is received in the office indicating that a service that was billed is denied
due to bundling issues. The medical record is obtained and, upon review, it is
documented that the second procedure is a staged procedure that was planned at the
time of the initial procedure. When the claim is reviewed, no modifier was attached to
the codes on the claim. What should be done to resolve the claim? - ✔✔Add modifier 58
to the procedure and follow the payer's guidelines for appeals
,✔✔What type of denial is more likely to happen when the patient is insured through an
HMO? - ✔✔No referral
✔✔Best practice to prevent receiving a denial due to coverage termination would be to:
- ✔✔Verify coverage prior to the patient's scheduled appointment.
✔✔What is the first step in the majority of denial cases, that you should take? - ✔✔Call
the insurance company and find out why the claim is being denied.
✔✔The liaison between BCBS and the contracted provider community is known as
what? - ✔✔The insurance representative. Also known as the provider representative or
the provider network consultant.
✔✔In what box on the CMS-1500 form does a PA number get placed? - ✔✔Box 23
✔✔A health insurance plan that reimburses for healthcare services provided to
members based on providers bills submitted after the services are rendered is known
as: - ✔✔Traditional insurance. Also known as Fee-for-service, or an indemnity plan.
✔✔What is the difference between non-covered services and not medically necessary
services? - ✔✔Non-covered services are pre-determined to not be re-reimbursable by
the insurance while not-medically necessary services have been found to not be
necessary for the evaluation and treatment of an individuals disease, condition, illness,
or injury.
✔✔When a patient presents for their appointment, insurance coverage should be
verified and: - ✔✔A copy should be made of both the front and back of the member's
insurance card.
✔✔For which denial is it acceptable to balance bill the patient? - ✔✔Non-covered
service
✔✔BCBS offers which type of Medicare plan? - ✔✔A medicare advantage plan (part C)
✔✔A participating provider of BCBS sees a patient in the ER. The charges equal $500.
The patient has a $1000 deductible of which none has been met, and a $75 ER copay,
How much should be collected from the patient for this service? - ✔✔$75
✔✔What is a copay? - ✔✔A fixed amount of money that you will pay for an office visit
*same day*.
✔✔What is a deductable? - ✔✔The amount of money you need to pay for services
before insurance will pay anything.
, ✔✔What is Co-insurance? - ✔✔The amount of money you will pay for services after the
deductible is met but *before* you have reached your maximum out of pocket amount.
✔✔What is Out-of-pocket? - ✔✔The amount of money you need to pay out of pocket
*before* insurance will pay at 100%.
✔✔What are the 4 parts of Medicare? - ✔✔A,B,C,D
✔✔What does Medicare A cover? - ✔✔Hospital services
✔✔What does Medicare B cover? - ✔✔Out-patient services
✔✔What is Medicare C? - ✔✔This is a Medicare replacement plan for A+B offered by
private companies that are contracted with Medicare. AKA a medicare advantage plan.
✔✔What is Medicare D? - ✔✔Coverage for prescription medicine
✔✔A patient receiving inpatient care in a critical access hospital would be covered
under which part of Medicare? - ✔✔Part A
✔✔For services such as screening for depression, bone mass measurements, and
glaucoma screenings, what does Medicate consider these services to be? -
✔✔Preventative
✔✔To determine the Medicare coverage and payment policy for a service or procedure,
which resources will indicate if a service or procedure is payable, non-covered, or
bundled into another service? - ✔✔Status codes
✔✔Medigap policies must conform to minimum standards identified as federal and state
laws and clearly be identified as: - ✔✔Medicare supplemental insurance
✔✔Allen who is a non-par provide who doesn't accept assignment performs an
appendectomy on a 67 year old Medicare patient. The physician's UCR for the surgery
is $1500. Medicare's approved fee for this procedure is $1100. What is the charge that
this non-par provider can charge to this Medicare patient? - ✔✔$1201.75
✔✔A Medicare patient is seen by a participating provider. A claim is sent for $123 and
an EOMB is received that states the approved amount is $100. If the patient has met
their deductible, what should the reimbursement on this claim be from Medicare? -
✔✔$80
