©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
AAPC CPB Practice Exam A Questions
and 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. - ANSWER✔✔-ANSWER:
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.
Page 1/35
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
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 - ANSWER✔✔-ANSWER:
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
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, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
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 - ANSWER✔✔-ANSWER:
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?
Page 3/35
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
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 - ANSWER✔✔-ANSWER:
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 - ANSWER✔✔-ANSWER:
Page 4/35
FIRST PUBLISH OCTOBER 2024
AAPC CPB Practice Exam A Questions
and 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. - ANSWER✔✔-ANSWER:
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.
Page 1/35
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
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 - ANSWER✔✔-ANSWER:
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
Page 2/35
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
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 - ANSWER✔✔-ANSWER:
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?
Page 3/35
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
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 - ANSWER✔✔-ANSWER:
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 - ANSWER✔✔-ANSWER:
Page 4/35
