1|Page
AAPC CPB Practice Exam/ 459 Q&A/ A+ Score
Solution/ .
Joe and Mary are a married couple and both carry insurance from their
employers. Joe was born on February 23, 1977 and Mary was born on April 4,
1974. 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 date of birth is the 4th and Joe's date of birth 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. -
(answers)D. Joe, because his birth month and day are before Mary's birth month
and day.
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
,2|Page
B. IV
C. II and IV
D. II, III, and V - (answers)C. II and IV
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 - (answers)C. $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 if he accepts assignment.
,3|Page
D. The claim is not paid because the provider is not participating in the plan. -
(answers)A. The payment is sent to the patient and the patient must pay 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 - (answers)B. TRICARE Prime
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
, 4|Page
C. I-III, VI
D. I, II, IV, V - (answers)B. I, IV
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 - (answers)B. II and III
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"
AAPC CPB Practice Exam/ 459 Q&A/ A+ Score
Solution/ .
Joe and Mary are a married couple and both carry insurance from their
employers. Joe was born on February 23, 1977 and Mary was born on April 4,
1974. 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 date of birth is the 4th and Joe's date of birth 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. -
(answers)D. Joe, because his birth month and day are before Mary's birth month
and day.
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
,2|Page
B. IV
C. II and IV
D. II, III, and V - (answers)C. II and IV
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 - (answers)C. $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 if he accepts assignment.
,3|Page
D. The claim is not paid because the provider is not participating in the plan. -
(answers)A. The payment is sent to the patient and the patient must pay 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 - (answers)B. TRICARE Prime
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
, 4|Page
C. I-III, VI
D. I, II, IV, V - (answers)B. I, IV
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 - (answers)B. II and III
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"
