CPB 2026 Exam Prep: Certified Professional
Biller Practice Questions with Answer Rationales
Claims Processing | Reimbursement | Insurance |
Billing Compliance | Patient Accounts Review
SECTION 1: TYPES OF INSURANCE (Questions 1–29)
1. A patient presents with a Medicare Advantage (Part C) plan. Which entity
is responsible for processing the patient's claim?
A) The Centers for Medicare & Medicaid Services (CMS) directly
B) The private insurance company contracted with Medicare to provide the
plan
C) The state Medicaid agency
D) The patient's employer
Rationale: Medicare Advantage (Part C) plans are offered by private insurance
companies approved by Medicare. These companies administer the plan and
process claims, not CMS directly. The private insurer is responsible for paying
providers according to the plan's terms.
2. Which government program provides healthcare coverage for active-duty
military members and their families?
A) Medicare
B) Medicaid
C) TRICARE
D) Veterans Affairs (VA)
Rationale: TRICARE is the healthcare program for active-duty service members,
retirees, and their families. The VA provides care for veterans, while Medicare and
Medicaid serve different populations.
,3. A patient has both primary and secondary insurance coverage. How should
the claim be submitted?
A) Submit only to the secondary payer
B) Submit to the primary payer first, then submit to the secondary payer with
the primary's Explanation of Benefits (EOB)
C) Submit to both payers simultaneously
D) Submit only to the primary payer
Rationale: When a patient has dual coverage, the claim must be submitted to the
primary payer first. After the primary processes the claim and issues an EOB, the
claim is submitted to the secondary payer along with the EOB to determine
remaining patient responsibility.
4. Under Medicare Secondary Payer (MSP) rules, which of the following is a
situation where Medicare would be the secondary payer?
A) The patient has no other insurance
B) The patient is covered by a group health plan through their employer (with
20+ employees)
C) The patient has only Medicare Part A
D) The patient is enrolled in a Medicare Advantage plan
Rationale: Under MSP rules, Medicare is secondary when a beneficiary has group
health plan coverage through their own or a spouse's current employer with 20 or
more employees. Medicare pays secondary to workers' compensation, no-fault
insurance, and liability insurance as well.
5. What is the birthday rule in coordination of benefits for a dependent child
covered by both parents' insurance plans?
A) The parent with the higher income is primary
B) The parent whose birthday falls earlier in the calendar year is primary
,C) The father is always primary
D) The mother is always primary
Rationale: The birthday rule states that the parent whose birthday (month and day)
falls earlier in the calendar year is considered the primary insurer for dependent
children. This applies when both parents have the child covered under their plans.
6. Which of the following is a characteristic of a Health Maintenance
Organization (HMO)?
A) Patients can see any provider without a referral
B) Patients must select a primary care physician (PCP) and obtain referrals
for specialists
C) Patients have a high deductible with a health savings account
D) Providers are paid on a fee-for-service basis only
Rationale: HMOs require patients to choose a primary care physician (PCP) who
coordinates care and provides referrals to specialists. Care outside the network is
generally not covered except in emergencies. HMOs typically use capitation or
discounted fee-for-service payment models.
7. What is a Preferred Provider Organization (PPO)?
A) A plan that requires referrals for all specialists
B) A plan that offers a network of preferred providers with financial
incentives to use them, but allows out-of-network care at a higher cost
C) A plan with no deductible
D) A government-funded health plan
Rationale: PPOs contract with a network of preferred providers. Patients can see
providers outside the network but pay higher copayments, coinsurance, and
deductibles. No referral is required to see specialists.
, 8. What is a Health Savings Account (HSA) and how does it relate to a High
Deductible Health Plan (HDHP)?
A) An HSA is only available to Medicare beneficiaries
B) An HSA is a tax-advantaged savings account available to individuals
enrolled in a qualified HDHP
C) An HSA is a type of insurance plan
D) An HSA is only available to self-employed individuals
Rationale: An HSA is a tax-advantaged medical savings account available to
taxpayers enrolled in a High Deductible Health Plan (HDHP). Funds can be used
for qualified medical expenses, and unused balances roll over year to year.
9. Which of the following is a characteristic of a Consumer-Driven Health
Plan (CDHP)?
A) Low deductible with high premiums
B) High deductible with a tax-advantaged savings account (e.g., HSA or HRA)
C) No deductible
D) Only available through employers
Rationale: Consumer-Driven Health Plans (CDHPs) combine a high-deductible
health plan with a tax-advantaged savings account such as an HSA or Health
Reimbursement Arrangement (HRA). The patient pays more out-of-pocket initially
but has lower premiums.
10. What is the role of a Third-Party Administrator (TPA)?
A) Provides direct patient care
B) Processes claims and administers benefits on behalf of a self-funded
employer plan
C) Issues insurance policies directly to individuals
D) Regulates insurance companies
Biller Practice Questions with Answer Rationales
Claims Processing | Reimbursement | Insurance |
Billing Compliance | Patient Accounts Review
SECTION 1: TYPES OF INSURANCE (Questions 1–29)
1. A patient presents with a Medicare Advantage (Part C) plan. Which entity
is responsible for processing the patient's claim?
A) The Centers for Medicare & Medicaid Services (CMS) directly
B) The private insurance company contracted with Medicare to provide the
plan
C) The state Medicaid agency
D) The patient's employer
Rationale: Medicare Advantage (Part C) plans are offered by private insurance
companies approved by Medicare. These companies administer the plan and
process claims, not CMS directly. The private insurer is responsible for paying
providers according to the plan's terms.
2. Which government program provides healthcare coverage for active-duty
military members and their families?
A) Medicare
B) Medicaid
C) TRICARE
D) Veterans Affairs (VA)
Rationale: TRICARE is the healthcare program for active-duty service members,
retirees, and their families. The VA provides care for veterans, while Medicare and
Medicaid serve different populations.
,3. A patient has both primary and secondary insurance coverage. How should
the claim be submitted?
A) Submit only to the secondary payer
B) Submit to the primary payer first, then submit to the secondary payer with
the primary's Explanation of Benefits (EOB)
C) Submit to both payers simultaneously
D) Submit only to the primary payer
Rationale: When a patient has dual coverage, the claim must be submitted to the
primary payer first. After the primary processes the claim and issues an EOB, the
claim is submitted to the secondary payer along with the EOB to determine
remaining patient responsibility.
4. Under Medicare Secondary Payer (MSP) rules, which of the following is a
situation where Medicare would be the secondary payer?
A) The patient has no other insurance
B) The patient is covered by a group health plan through their employer (with
20+ employees)
C) The patient has only Medicare Part A
D) The patient is enrolled in a Medicare Advantage plan
Rationale: Under MSP rules, Medicare is secondary when a beneficiary has group
health plan coverage through their own or a spouse's current employer with 20 or
more employees. Medicare pays secondary to workers' compensation, no-fault
insurance, and liability insurance as well.
5. What is the birthday rule in coordination of benefits for a dependent child
covered by both parents' insurance plans?
A) The parent with the higher income is primary
B) The parent whose birthday falls earlier in the calendar year is primary
,C) The father is always primary
D) The mother is always primary
Rationale: The birthday rule states that the parent whose birthday (month and day)
falls earlier in the calendar year is considered the primary insurer for dependent
children. This applies when both parents have the child covered under their plans.
6. Which of the following is a characteristic of a Health Maintenance
Organization (HMO)?
A) Patients can see any provider without a referral
B) Patients must select a primary care physician (PCP) and obtain referrals
for specialists
C) Patients have a high deductible with a health savings account
D) Providers are paid on a fee-for-service basis only
Rationale: HMOs require patients to choose a primary care physician (PCP) who
coordinates care and provides referrals to specialists. Care outside the network is
generally not covered except in emergencies. HMOs typically use capitation or
discounted fee-for-service payment models.
7. What is a Preferred Provider Organization (PPO)?
A) A plan that requires referrals for all specialists
B) A plan that offers a network of preferred providers with financial
incentives to use them, but allows out-of-network care at a higher cost
C) A plan with no deductible
D) A government-funded health plan
Rationale: PPOs contract with a network of preferred providers. Patients can see
providers outside the network but pay higher copayments, coinsurance, and
deductibles. No referral is required to see specialists.
, 8. What is a Health Savings Account (HSA) and how does it relate to a High
Deductible Health Plan (HDHP)?
A) An HSA is only available to Medicare beneficiaries
B) An HSA is a tax-advantaged savings account available to individuals
enrolled in a qualified HDHP
C) An HSA is a type of insurance plan
D) An HSA is only available to self-employed individuals
Rationale: An HSA is a tax-advantaged medical savings account available to
taxpayers enrolled in a High Deductible Health Plan (HDHP). Funds can be used
for qualified medical expenses, and unused balances roll over year to year.
9. Which of the following is a characteristic of a Consumer-Driven Health
Plan (CDHP)?
A) Low deductible with high premiums
B) High deductible with a tax-advantaged savings account (e.g., HSA or HRA)
C) No deductible
D) Only available through employers
Rationale: Consumer-Driven Health Plans (CDHPs) combine a high-deductible
health plan with a tax-advantaged savings account such as an HSA or Health
Reimbursement Arrangement (HRA). The patient pays more out-of-pocket initially
but has lower premiums.
10. What is the role of a Third-Party Administrator (TPA)?
A) Provides direct patient care
B) Processes claims and administers benefits on behalf of a self-funded
employer plan
C) Issues insurance policies directly to individuals
D) Regulates insurance companies
