CPB Final Exam Questions AND Correct Answers
A _____ is a correspondence sent from the insurance payer to
the patient after they receive healthcare services to explain
the status of their claim. - ✔✔Explanation of Benefits
A 21 year-old patient presents for fillings for two of his teeth.
Are these services covered under EPSDT? - ✔✔No, because
the patient is not under the age of 21.
A BC/BS insurance plan that allows members to choose any
provider, but offers higher level of coverage when members
obtain services from network provider would be an example
of: - ✔✔PPO
A biller at a medical practice notices that all claims contain
CPT code 81002. She questions the nurse who tells her that
because they are an OB/GYN office they bill every patient for
a urinalysis. What does this violate? - ✔✔False Claims Act
A biller receives a request for medical records for patient A for
DOS 05/15/20XX. Patient A's entire medical record (multiple
dates of service) was copied and sent to the insurance carrier.
,Which statement below is true? - ✔✔This is a violation of
HIPAA.
A claim has been denied as not medically necessary. The biller
has checked the medical record and the medical policy and
verified it is not covered according to the carrier's medical
policy. What is the next action the biller should take? -
✔✔Check with the provider to appeal the claim and if
necessary write off the balance.
A claim is submitted for a patient on Medicare with a higher
fee than a patient on Insurance ABC. What is this considered
by CMS? - ✔✔Abuse
A claim was resubmitted to Medicare through a clearinghouse
60 days after the date of service and the claim was denied.
The biller checked the clearinghouse claim status system and
determined Medicare did not receive the claim. What action
should the biller take? - ✔✔Check the clearinghouse reports
and appeal the denial with proof of the claims submission.
A denial is received for services bundled into the global
period. The record is reviewed and it is found that the denial
is for a staged service that fell within the global days of the
,initial service. There were no modifiers appended to the codes
on the claim form. What should be done? - ✔✔A modifier
should be attached to the claim to show staged procedure and
the claim should be appealed.
A denial is received in the office for timely filing. The payer
has a 60 day timely filing policy for appeals. The internal
process is investigated and it is found that the appeal was
filed at 90 days. What can be done? - ✔✔Write off the claim
amount
A denial is received in the office from a patient's insurance
company. It stated that the services billed are not covered due
to exclusions under the patient's plan. What should be done
at this point? - ✔✔The patient should be balance billed
A hospital records transported is moving medical records from
the hospital to an off-site building. During the transport, a
chart falls from the box onto the street. It is discovered when
the transporter arrives at the off-site building and the number
of charts is not correct. What type of violation is this? - ✔✔A
breach
, A Medicare patient has prescription drug coverage, but does
not have Medicare Advantage. What Medicare coverage does
the patient have for his medications? - ✔✔Part D
A Medicare patient is seen by a participating provider. A claim
is sent for $123.00 and an EOMB is received that states the
approved amount is $100.00. If the patient has met their
deductible, what should the reimbursement on this claim be
from Medicare? - ✔✔$80.00
A Medicare patient is seen by her physician. The physician has
opted out of the Medicare program. The patient and physician
have a private contract. The charges for the service rendered
are $300.00. Medicare's approved amount would be $200.00.
What can the office charge this patient? - ✔✔$300.00
A Medicare patient presents for her pelvic, pap, and breast
examination (PPB). The patient is not sure when she had her
last PPB. As she is checking out, the front desk rep has her sign
an ABN. The service is billed and denied for frequency. Can
the patient be balance billed and why or why not? - ✔✔No.
The ABN must be signed before the service is preformed.
A _____ is a correspondence sent from the insurance payer to
the patient after they receive healthcare services to explain
the status of their claim. - ✔✔Explanation of Benefits
A 21 year-old patient presents for fillings for two of his teeth.
Are these services covered under EPSDT? - ✔✔No, because
the patient is not under the age of 21.
A BC/BS insurance plan that allows members to choose any
provider, but offers higher level of coverage when members
obtain services from network provider would be an example
of: - ✔✔PPO
A biller at a medical practice notices that all claims contain
CPT code 81002. She questions the nurse who tells her that
because they are an OB/GYN office they bill every patient for
a urinalysis. What does this violate? - ✔✔False Claims Act
A biller receives a request for medical records for patient A for
DOS 05/15/20XX. Patient A's entire medical record (multiple
dates of service) was copied and sent to the insurance carrier.
,Which statement below is true? - ✔✔This is a violation of
HIPAA.
A claim has been denied as not medically necessary. The biller
has checked the medical record and the medical policy and
verified it is not covered according to the carrier's medical
policy. What is the next action the biller should take? -
✔✔Check with the provider to appeal the claim and if
necessary write off the balance.
A claim is submitted for a patient on Medicare with a higher
fee than a patient on Insurance ABC. What is this considered
by CMS? - ✔✔Abuse
A claim was resubmitted to Medicare through a clearinghouse
60 days after the date of service and the claim was denied.
The biller checked the clearinghouse claim status system and
determined Medicare did not receive the claim. What action
should the biller take? - ✔✔Check the clearinghouse reports
and appeal the denial with proof of the claims submission.
A denial is received for services bundled into the global
period. The record is reviewed and it is found that the denial
is for a staged service that fell within the global days of the
,initial service. There were no modifiers appended to the codes
on the claim form. What should be done? - ✔✔A modifier
should be attached to the claim to show staged procedure and
the claim should be appealed.
A denial is received in the office for timely filing. The payer
has a 60 day timely filing policy for appeals. The internal
process is investigated and it is found that the appeal was
filed at 90 days. What can be done? - ✔✔Write off the claim
amount
A denial is received in the office from a patient's insurance
company. It stated that the services billed are not covered due
to exclusions under the patient's plan. What should be done
at this point? - ✔✔The patient should be balance billed
A hospital records transported is moving medical records from
the hospital to an off-site building. During the transport, a
chart falls from the box onto the street. It is discovered when
the transporter arrives at the off-site building and the number
of charts is not correct. What type of violation is this? - ✔✔A
breach
, A Medicare patient has prescription drug coverage, but does
not have Medicare Advantage. What Medicare coverage does
the patient have for his medications? - ✔✔Part D
A Medicare patient is seen by a participating provider. A claim
is sent for $123.00 and an EOMB is received that states the
approved amount is $100.00. If the patient has met their
deductible, what should the reimbursement on this claim be
from Medicare? - ✔✔$80.00
A Medicare patient is seen by her physician. The physician has
opted out of the Medicare program. The patient and physician
have a private contract. The charges for the service rendered
are $300.00. Medicare's approved amount would be $200.00.
What can the office charge this patient? - ✔✔$300.00
A Medicare patient presents for her pelvic, pap, and breast
examination (PPB). The patient is not sure when she had her
last PPB. As she is checking out, the front desk rep has her sign
an ABN. The service is billed and denied for frequency. Can
the patient be balance billed and why or why not? - ✔✔No.
The ABN must be signed before the service is preformed.
