AAPC CPB 2027 SETS ANSWERS AND QUESTIONS
SET A+
✔✔ESRD or EPSDT is a reason to receive Medicare coverage? - ✔✔ESRD
✔✔MCR or MCD- which of these programs are state ran? - ✔✔MCD
✔✔What disease is a qualifier for Medicare coverage and spurred on the national Ice
Bucket Challenge Craze? - ✔✔ALS
✔✔Which of the following are modifiers used with ABN's - ✔✔GA
GX
GY
GZ
*all of the above*
✔✔Which are mid-level provider credentials? - ✔✔PA
ANP
CNM
*all of the above*
✔✔The office receives an RA from a commercial payer. One of the denials has a
reason code of CO97; Benefit included in payment/allowance for another service. What
type of denial is this? - ✔✔Bundled services
✔✔What should a biller do if a medical necessity denial is received from an insurer? -
✔✔The medical record should be pulled, reviewed, and assessed
✔✔What is the difference between a rejected claim and a denied claim? - ✔✔A
rejection cannot be appealed
,✔✔A denial is received in the office from a patient's insurance company. It stated that
the services billed are not covered due to exclusions under the patient's plan. What
should be done at this point? - ✔✔The patient should be balance billed
✔✔An RA is received that contains a denial for a coordination of benefits issue. What
could this mean? - ✔✔b. Another insurer is primary
c. The claim was submitted without the primary insurance RA
*both b and c*
✔✔According to the Patient Protection and Affordable Care Act, and insurance plan
must offer? - ✔✔Internal and external review processes
✔✔What type of denial indicates there may be an issue with the front desk
registration/intake policies? - ✔✔Eligibility expired
✔✔A denial is received for services bundled into the global period. The record is
reviewed and it is found that the denial is for a staged service that fell within the global
days of the initial service. There were no modifiers appended to the codes on the claim
form. What should be done? - ✔✔A modifier should be attached to the claim to show
staged procedure and the claim should be appealed.
✔✔What is a timely filing requirement? - ✔✔The time frame a provider has to submit a
claim.
✔✔A _____ is a correspondence sent from the insurance payer to the patient after they
receive healthcare services to explain the status of their claim. - ✔✔Explanation of
Benefits
✔✔Which one of the following is NOT a data entry denial? - ✔✔Coverage Terminated
✔✔What does being a "participating provider" agrees to when signing a contract with an
insurance payer? - ✔✔The provider wishes to participate with and agree to accept the
fee schedules set by that specific insurance.
✔✔Which of the following type of insurance that allows members to choose medical
services as needed and can go in or out of network. - ✔✔POS
✔✔Which of the following is an account that is usually funded by the employee only and
reimburses employee for specified expenses as they are incurred? - ✔✔FSA
✔✔What role does an Insurance Provider Representative play? - ✔✔Is the liaison
between the insurance payer and the provider.
, ✔✔The provider, hospital, or other entity that agrees to provide healthcare services to
an insurance plan's enrollees is a: - ✔✔Participating provider
✔✔Balance billing by participating providers is: - ✔✔Not allowed under a participating
provider's contract
✔✔What information can be found on a Blue Cross Blue Shield - ✔✔
✔✔What information can be found on a Blue Cross Blue Shield insurance identification
card? - ✔✔A type of plan
C ID number
D group number
F phone number for member service/benefits questions
G mailing address of BC/BS office
*4 a,c,d,f,g*
✔✔A BC/BS insurance plan that allows members to choose any provider, but offers
higher level of coverage when members obtain services from network provider would be
an example of: - ✔✔PPO
✔✔Carl has enrolled in a healthcare insurance plan that allows him to choose to have
services within the BC/BS network or outside of the network. What type of plan best
describes Carl's insurance coverage? - ✔✔Point of Service
✔✔Jared is employed with the United States Internal Revenue Service and has enrolled
in the BC/BS healthcare insurance offered through his employer. What is the name of
the BC/BS insurance program offered by the federal government? - ✔✔Federal
Employee Program
✔✔Tony's BC/BS healthcare insurance policy states that he must seek healthcare
services only from providers that are part of a specific network. What type of BC/BS
plan does Tony have? - ✔✔HMO
✔✔BC/BS identifies the individual who pays for healthcare insurance coverage as the: -
✔✔Subscriber
✔✔BC/BS identifies the individual who is eligible for covered services as the: -
✔✔Member
✔✔Participating providers agree to: - ✔✔Accept the fee schedules determined by the
insurance company.
SET A+
✔✔ESRD or EPSDT is a reason to receive Medicare coverage? - ✔✔ESRD
✔✔MCR or MCD- which of these programs are state ran? - ✔✔MCD
✔✔What disease is a qualifier for Medicare coverage and spurred on the national Ice
Bucket Challenge Craze? - ✔✔ALS
✔✔Which of the following are modifiers used with ABN's - ✔✔GA
GX
GY
GZ
*all of the above*
✔✔Which are mid-level provider credentials? - ✔✔PA
ANP
CNM
*all of the above*
✔✔The office receives an RA from a commercial payer. One of the denials has a
reason code of CO97; Benefit included in payment/allowance for another service. What
type of denial is this? - ✔✔Bundled services
✔✔What should a biller do if a medical necessity denial is received from an insurer? -
✔✔The medical record should be pulled, reviewed, and assessed
✔✔What is the difference between a rejected claim and a denied claim? - ✔✔A
rejection cannot be appealed
,✔✔A denial is received in the office from a patient's insurance company. It stated that
the services billed are not covered due to exclusions under the patient's plan. What
should be done at this point? - ✔✔The patient should be balance billed
✔✔An RA is received that contains a denial for a coordination of benefits issue. What
could this mean? - ✔✔b. Another insurer is primary
c. The claim was submitted without the primary insurance RA
*both b and c*
✔✔According to the Patient Protection and Affordable Care Act, and insurance plan
must offer? - ✔✔Internal and external review processes
✔✔What type of denial indicates there may be an issue with the front desk
registration/intake policies? - ✔✔Eligibility expired
✔✔A denial is received for services bundled into the global period. The record is
reviewed and it is found that the denial is for a staged service that fell within the global
days of the initial service. There were no modifiers appended to the codes on the claim
form. What should be done? - ✔✔A modifier should be attached to the claim to show
staged procedure and the claim should be appealed.
✔✔What is a timely filing requirement? - ✔✔The time frame a provider has to submit a
claim.
✔✔A _____ is a correspondence sent from the insurance payer to the patient after they
receive healthcare services to explain the status of their claim. - ✔✔Explanation of
Benefits
✔✔Which one of the following is NOT a data entry denial? - ✔✔Coverage Terminated
✔✔What does being a "participating provider" agrees to when signing a contract with an
insurance payer? - ✔✔The provider wishes to participate with and agree to accept the
fee schedules set by that specific insurance.
✔✔Which of the following type of insurance that allows members to choose medical
services as needed and can go in or out of network. - ✔✔POS
✔✔Which of the following is an account that is usually funded by the employee only and
reimburses employee for specified expenses as they are incurred? - ✔✔FSA
✔✔What role does an Insurance Provider Representative play? - ✔✔Is the liaison
between the insurance payer and the provider.
, ✔✔The provider, hospital, or other entity that agrees to provide healthcare services to
an insurance plan's enrollees is a: - ✔✔Participating provider
✔✔Balance billing by participating providers is: - ✔✔Not allowed under a participating
provider's contract
✔✔What information can be found on a Blue Cross Blue Shield - ✔✔
✔✔What information can be found on a Blue Cross Blue Shield insurance identification
card? - ✔✔A type of plan
C ID number
D group number
F phone number for member service/benefits questions
G mailing address of BC/BS office
*4 a,c,d,f,g*
✔✔A BC/BS insurance plan that allows members to choose any provider, but offers
higher level of coverage when members obtain services from network provider would be
an example of: - ✔✔PPO
✔✔Carl has enrolled in a healthcare insurance plan that allows him to choose to have
services within the BC/BS network or outside of the network. What type of plan best
describes Carl's insurance coverage? - ✔✔Point of Service
✔✔Jared is employed with the United States Internal Revenue Service and has enrolled
in the BC/BS healthcare insurance offered through his employer. What is the name of
the BC/BS insurance program offered by the federal government? - ✔✔Federal
Employee Program
✔✔Tony's BC/BS healthcare insurance policy states that he must seek healthcare
services only from providers that are part of a specific network. What type of BC/BS
plan does Tony have? - ✔✔HMO
✔✔BC/BS identifies the individual who pays for healthcare insurance coverage as the: -
✔✔Subscriber
✔✔BC/BS identifies the individual who is eligible for covered services as the: -
✔✔Member
✔✔Participating providers agree to: - ✔✔Accept the fee schedules determined by the
insurance company.
