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MEDICAL BILLING CERTIFICATION ACTUAL
EXAM 2026/2027 COMPLETE ACCURATE
EXAM REAL QUESTIONS WITH WELL
ELABORATED ANSWERS AND RATIONALES.
(100% CORRECT VERIFIED SOLUTIONS)
1. A patient with NY Medicaid is seen for an emergency room
visit. The service is not pre-authorized. Under NYS Medicaid
rules, which is true?
A) The claim will be automatically denied
B) Emergency services do not require prior authorization in NY
C) The patient must sign a waiver of liability
D) The provider must bill Medicare first
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Answer: B
Rationale: NY Medicaid (eMedNY) does not require prior
authorization for bona fide emergency services. Non-
emergency services may require prior approval.
2. A New York provider participates in Medicare but not in
No-Fault auto insurance. A patient injured in a car accident in
NYC seeks treatment. How should the provider bill?
A) Bill Medicare as primary
B) Bill No-Fault as primary, even if non-participating
C) Bill the patient directly
D) Bill NY Medicaid
Answer: B
Rationale: NY No-Fault is primary over Medicare for auto
accident injuries, regardless of provider participation status.
The provider must bill No-Fault first.
3. Which NY law requires surprise billing protections for
patients receiving emergency or scheduled services from out-
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of-network providers at in-network facilities?
A) NY Public Health Law § 2805-t
B) NY Insurance Law § 3217-b
C) The federal No Surprises Act (effective 2022)
D) Both B and C
Answer: D
Rationale: NY passed its own surprise billing law (§ 3217-b),
but the federal No Surprises Act supersedes or supplements it
in many cases. Both apply depending on plan type.
4. A billing specialist in NY discovers a duplicate claim was
paid. What is the required action under NY and federal law?
A) Keep the overpayment and adjust future claims
B) Notify the payer and refund within 60 days
C) Wait for the payer to request a refund
D) Write off the amount as bad debt
Answer: B
Rationale: Under the federal False Claims Act and NY law,
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overpayments must be reported and refunded within 60 days
of identification.
5. Scenario: A patient with NY Empire Plan (state employee
health insurance) receives a service that is denied as “not
medically necessary.” The provider disagrees. What is the first
step in NY external appeal?
A) File a lawsuit in NY Supreme Court
B) Request an internal appeal with Empire Plan
C) Submit to the NY Department of Financial Services (DFS)
external appeal
D) Bill the patient directly
Answer: B
Rationale: NY external appeal requires exhaustion of the
plan’s internal appeal process first. DFS external appeal is
step two.
6. Under NY Workers’ Compensation, how many days does a
provider have to submit the initial bill (CMS-1500 or UB-04)
MEDICAL BILLING CERTIFICATION ACTUAL
EXAM 2026/2027 COMPLETE ACCURATE
EXAM REAL QUESTIONS WITH WELL
ELABORATED ANSWERS AND RATIONALES.
(100% CORRECT VERIFIED SOLUTIONS)
1. A patient with NY Medicaid is seen for an emergency room
visit. The service is not pre-authorized. Under NYS Medicaid
rules, which is true?
A) The claim will be automatically denied
B) Emergency services do not require prior authorization in NY
C) The patient must sign a waiver of liability
D) The provider must bill Medicare first
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Answer: B
Rationale: NY Medicaid (eMedNY) does not require prior
authorization for bona fide emergency services. Non-
emergency services may require prior approval.
2. A New York provider participates in Medicare but not in
No-Fault auto insurance. A patient injured in a car accident in
NYC seeks treatment. How should the provider bill?
A) Bill Medicare as primary
B) Bill No-Fault as primary, even if non-participating
C) Bill the patient directly
D) Bill NY Medicaid
Answer: B
Rationale: NY No-Fault is primary over Medicare for auto
accident injuries, regardless of provider participation status.
The provider must bill No-Fault first.
3. Which NY law requires surprise billing protections for
patients receiving emergency or scheduled services from out-
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of-network providers at in-network facilities?
A) NY Public Health Law § 2805-t
B) NY Insurance Law § 3217-b
C) The federal No Surprises Act (effective 2022)
D) Both B and C
Answer: D
Rationale: NY passed its own surprise billing law (§ 3217-b),
but the federal No Surprises Act supersedes or supplements it
in many cases. Both apply depending on plan type.
4. A billing specialist in NY discovers a duplicate claim was
paid. What is the required action under NY and federal law?
A) Keep the overpayment and adjust future claims
B) Notify the payer and refund within 60 days
C) Wait for the payer to request a refund
D) Write off the amount as bad debt
Answer: B
Rationale: Under the federal False Claims Act and NY law,
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overpayments must be reported and refunded within 60 days
of identification.
5. Scenario: A patient with NY Empire Plan (state employee
health insurance) receives a service that is denied as “not
medically necessary.” The provider disagrees. What is the first
step in NY external appeal?
A) File a lawsuit in NY Supreme Court
B) Request an internal appeal with Empire Plan
C) Submit to the NY Department of Financial Services (DFS)
external appeal
D) Bill the patient directly
Answer: B
Rationale: NY external appeal requires exhaustion of the
plan’s internal appeal process first. DFS external appeal is
step two.
6. Under NY Workers’ Compensation, how many days does a
provider have to submit the initial bill (CMS-1500 or UB-04)
