Module # 2. Certified Billing & Coding Specialist Study Guide 3.0
Insurance Eligibility and Other Payer Requirements.
1) A patient completes their provider’s office registration forms and provide a military ID with a
TRICARE card. The billing and coding specialist should use which of the following to verify the
patient’s their-party payer eligibility?
a) My answer: The Electronic Data Interchange (EDI)
i) The EDI is an insurance eligibility process for Medicare beneficiaries.
2) A patient is scheduled for a procedure with an allowed amount of $2,500. And the annual deductible
of $700 has been met. The coinsurance agreement is 70/30. Which of the following is the patient’s
responsibility?
a) My answer: $1,450
i) This amount includes the deductible and the patient’s 30% coinsurance. The annual
deductible amount has already been met so it should not be included in the calculation.
3) A patient who has Medicare coverage requests a pain medication replacement surgery. For which of
the following parts of Medicare should the patient’s eligibility be verified for the prescription?
a) My answer: Part B
i) Medicare Part B pays for professional and outpatient services.
4) A billing and coding specialist is reviewing a patient’s record. The specialist should recognize that
which the following should be signed by the patient if there is a concern that Medicare night not pay
for the service?
a) My answer: Informed consent form.
i) An informed consent form gives permission to treat the patient.
5) Which of the following parts of Medicare determines eligibility for dental services?
a) My answer: Part A
i) Medicare Part A covers inpatient hospital services.
6) A billing a coding specialist is preparing a claim for a 69-year-old patient who was involved in a
motor-vehicle crash. The specialist should submit the primary claim to which of the following third-
party payers?
a) My answer: Medicare.
i) Medicare is a federally controlled program that provides health care coverage to patients
who are 65 years or older and would be secondary coverage for a motor-vehicle crash.
7) A billing and coding specialist is calculating a patient’s financial responsibility for a procedure is $500
with no deductible required. If the insurance plan pays at 80/20, which is the patient’s total
coinsurance amount?
a) My answer: $280
i) This amount is equal to 20% of the total charge, which is incorrect. The patient’s copayment
is 20% of the allowable charge in an 80/20 plan.
8) A minor patient, whose parents are married, is covered under both parents’ group insurance plans
and also has Medicaid benefits. Parent A has a birthdate of June 6, 1988 and parent B has a
birthdate of October 23, 1987. Which of the following third-party payers sgould be biled as the
primary?
a) My answer: Either parent A’s or parent B’s insurance.
Insurance Eligibility and Other Payer Requirements.
1) A patient completes their provider’s office registration forms and provide a military ID with a
TRICARE card. The billing and coding specialist should use which of the following to verify the
patient’s their-party payer eligibility?
a) My answer: The Electronic Data Interchange (EDI)
i) The EDI is an insurance eligibility process for Medicare beneficiaries.
2) A patient is scheduled for a procedure with an allowed amount of $2,500. And the annual deductible
of $700 has been met. The coinsurance agreement is 70/30. Which of the following is the patient’s
responsibility?
a) My answer: $1,450
i) This amount includes the deductible and the patient’s 30% coinsurance. The annual
deductible amount has already been met so it should not be included in the calculation.
3) A patient who has Medicare coverage requests a pain medication replacement surgery. For which of
the following parts of Medicare should the patient’s eligibility be verified for the prescription?
a) My answer: Part B
i) Medicare Part B pays for professional and outpatient services.
4) A billing and coding specialist is reviewing a patient’s record. The specialist should recognize that
which the following should be signed by the patient if there is a concern that Medicare night not pay
for the service?
a) My answer: Informed consent form.
i) An informed consent form gives permission to treat the patient.
5) Which of the following parts of Medicare determines eligibility for dental services?
a) My answer: Part A
i) Medicare Part A covers inpatient hospital services.
6) A billing a coding specialist is preparing a claim for a 69-year-old patient who was involved in a
motor-vehicle crash. The specialist should submit the primary claim to which of the following third-
party payers?
a) My answer: Medicare.
i) Medicare is a federally controlled program that provides health care coverage to patients
who are 65 years or older and would be secondary coverage for a motor-vehicle crash.
7) A billing and coding specialist is calculating a patient’s financial responsibility for a procedure is $500
with no deductible required. If the insurance plan pays at 80/20, which is the patient’s total
coinsurance amount?
a) My answer: $280
i) This amount is equal to 20% of the total charge, which is incorrect. The patient’s copayment
is 20% of the allowable charge in an 80/20 plan.
8) A minor patient, whose parents are married, is covered under both parents’ group insurance plans
and also has Medicaid benefits. Parent A has a birthdate of June 6, 1988 and parent B has a
birthdate of October 23, 1987. Which of the following third-party payers sgould be biled as the
primary?
a) My answer: Either parent A’s or parent B’s insurance.
