AAPC CPB EXAM |ACTUAL QUESTIONS AND
VERIFIED ANSWERS|BRAND NEW 2026-2027
UPDATE|GRADED A+
Question 1
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.
CORRECT 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.
Question 2
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
1
,V. Capitation
A. II
B. IV
C. II and IV
D. II, III, and V
CORRECT 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 to pay a higher deductible, co-insurance, or co-
payment amount when he/she sees an out-of-network provider
Question 3
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
CORRECT ANSWER
ANSWER:
2
, 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.
Question 4
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
CORRECT 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.
Question 5
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
CORRECT ANSWER
ANSWER:
3
VERIFIED ANSWERS|BRAND NEW 2026-2027
UPDATE|GRADED A+
Question 1
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.
CORRECT 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.
Question 2
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
1
,V. Capitation
A. II
B. IV
C. II and IV
D. II, III, and V
CORRECT 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 to pay a higher deductible, co-insurance, or co-
payment amount when he/she sees an out-of-network provider
Question 3
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
CORRECT ANSWER
ANSWER:
2
, 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.
Question 4
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
CORRECT 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.
Question 5
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
CORRECT ANSWER
ANSWER:
3
