AAPC CPB Practice Exam A Questions & Answers

Joe and Mary are a married couple, and both carry insurance from their employers. Joe was born on February 23, 1987 and Mary was born on April 4, 1984. Using the birthday rule, who carries the primary insurance for their children for billing? A. Joe, because he is the male head of the household. B. Mary, because her DOB is the 4th and Joe's DOB is the 23rd. C. Mary, because her birth year is before Joe's birth year. D. Joe, because his birth month and day are before Mary's birth month and day. - ANSWERSANSWER: D - the birthday rule is used to determine coverage by primary and secondary policies when each parent subscribes to a different health insurance plan. the policy holder whose birth month and day occurs earlier in the calendar year holds the primary policy when each parent subscribes to a different health insurance plan. Which type of managed care insurance allows patients to self-refer to out-of-network providers and pay a higher co-insurance/copay amount? I. HMO II. PPO III. EPO IV. POS V. Capitation A. II B. IV C. II and IV D. II, III, and V - ANSWERSANSWER: C - Point-of-Service Plan (POS) and Preferred Provider Organization (PPO) allow patients the flexibility to self-refer to a specialist instead of requiring a referral from a primary care provider. A patient is required to pay a higher deductible, co-insurance, or co-payment amount when he/she sees an out-of-network provider A patient covered by a PPO is scheduled for knee replacement surgery. The biller contacts the insurance carrier to verify benefits and preauthorize the procedure. The carrier verifies the patient has a $500 deductible which must be met. After the deductible, the PPO will pay 80% of the claim. The contracted rate for the procedure is $2,500. What is the patient's responsibility? A. $400 B. $500 C. $900 D. $1,600 - ANSWERSANSWER: C - The contracted rate is $2500. The patient must pay the deductible ($500) and 20% of $2,000 ($400). The total patient responsibility is $900. When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment processed? A. The payment is sent to the patient and the patient must pay the provider B. The payment is sent to the provider if the provider agrees to accept assignment C. The payment is sent to the provider regardless of if he accepts assignment. D. The claim is not paid because the provider is not participating in the plan - ANSWERSANSWER: A - Even when nonparticipating providers with BC/BS agree to submit the claim for the patient or accept assignment, BC/BS sends the payment to the patient. The patient is responsible for paying the provider. Which of the following TRICARE options is/are available to active-duty service members? A. TRICARE Select B. TRICARE Prime C. TRICARE For Life D. TRICARE Young Adult - ANSWERSANSWER: B - All active-duty members must choose TRICARE Prime. TRICARE Select, TRICARE For Life, and TRICARE Young Adult are for active-duty family members. A Medicare card will list which of the following: I. Effective date of coverage II. Home address III. Telephone Number IV. Entitled to Part A and/or Part B V. When coverage ends VI. Name of Primary Care Physician A. I - VI B. I, IV C. I-III, VI D. I, II, IV, V - ANSWERSANSWER: B - Medicare card lists: The patient name Medicare claim number (or Medicare number) Effective date of coverage Sex/Gender Entitled to Medicare Part A and/or B (The card will not show if the patient has Part C or Part D coverage) Effective Date In which of the following scenarios is Medicare the secondary payer? I. A 65-year-old patient who is collecting her deceased spouse's Medicare benefits and has a supplemental insurance II. A 72-year-old patient who participates in the group health insurance of his employer III. A 66-year-old patient is injured at work and the employer does not offer health insurance as a benefit of employment IV. A 55-year-old patient who is on disability through Social Security and qualifies for Medicaid and Medicare A. I-IV B. II and III C. I and IV D. None - ANSWERSANSWER: B - Medicare is the secondary payer when the patient is eligible for Medicare and eligible for one of the following: Group health insurance through an employer Disability coverage through employer group health plan with more than 100 covered employees Patient with end-stage renal disease covered by employer group health plan during the first 30 months of the patient's eligibility for Medicare Third-party liability Workers' compensation VA benefits Federal black lung program When a patient has Medicare primary and AARP as Medigap, what is entered on the CMS-1500 claim form in item 9d for the Insurance Plan Name or Program Name for Medicare to cross over the claim? A. Plan name followed by "MEDIGAP" B. Plan Payer ID followed by "MEDIGAP" C. COBA Medigap claim-based identifier (ID) D. Leave blank - ANSWERSANSWER: C - From the Medicare Claims Processing Manual, Chapter 26 & Chapter 28 "Item 9d -Enter the 9-digit PAYERID number of the Medigap insurer. If no PAYERID number exists, then enter the Medigap insurance program or plan name.If the beneficiary wants Medicare payment data forwarded to a Medigap insurer through the Medigap claim-based crossover process, the participating provider of service or supplier must accurately complete all of the information in items 9, 9a, 9b, and 9d.A Medicare participating provider or supplier shall only enter the COBA Medigap claim-based ID within item 9d when seeking to have the beneficiary's claim crossed over to a Medigap insurer. If a participating provider or supplier enters the PAYERID or the Medigap insurer program or its plan name within item 9d, the Medicare Part B contractor or Durable Medical Equipment Medicare Administrative Contractor (DMAC) will be unable to forward the claim information to the Medigap insurer prior to October 1, 2007, or to the Coordination of Benefits Contractor (COBC) for transfer to the Medicare insurer on or after October 1, 2007. (See chapter 28 §70.6.4 of the CMS Medicare Claims Processing Manual for more information concerning the COBA Medigap claim-based crossover process.)" Which guidelines must all billing personnel be knowledgeable about in order to ensure compliance with Medicaid programs? A. Medicaid is covered only by federal guidelines. B. Medicaid is covered only by state guidelines. C. Both federal and state guidelines apply to Medicaid. D. Medicaid is only covered by international guidelines. - ANSWERSANSWER: C - Both federal and state guidelines apply. It is important to note that the state guidelines do not take precedence over federal guidelines and cannot contradict the basic requirements as set forth in the federal guidelines.