MEDICAL BILLING CODING ACTUAL LATEST 2026/2027
EXAM QUESTIONS AND ANSWERS RATED A+
✔✔What is the Difference between Fraud and abuse? - ✔✔Fraud is intentionally
misrepresenting services rendered for the purpose if receiving a higher payment. Abuse
refers to practices that are often done unknowingly as a result of poor business
practices, directly or indirectly resulting in unnecessary costs to the program through
improper payments.
✔✔What is the main job of the office inspector general?(OIG) - ✔✔Protects Medicare
and other HHS programs from fraud and abuse by conducting audits, investigations,
and inspections
✔✔Timely filing requirment - ✔✔Within 1 Calendar year of a claims date
✔✔Electronic data interchange (EDI) - ✔✔The transfer of electronic information in a
standard format
✔✔Coordination of benefits rule - ✔✔Determines which insurance plan is primary and
which is secondary insurance .
✔✔Conditional Payment - ✔✔Medicare payment that is recovered after primary
insurance pays.
✔✔Crossover claim - ✔✔Claim submitted by people covered by primary and secondary
insurance plan
✔✔Two causes of a claim transmission errors - ✔✔Missing or invalid patient
identification number and lack of authorization or referral number
✔✔Assignment of Benefits - ✔✔Contract in which the provider directly bills the payer
and accepts the allowable charge.
✔✔Clean claim - ✔✔Claim that is accurate and complete
✔✔Dirty claim - ✔✔Claim that inaccurate, incomplete, or contains other errors
✔✔Medicare administrative Contractor (MAC) - ✔✔Processes Medicare Parts A & B
claims from hospitals, physicians, and other providers
✔✔Remittance Advice (RA) - ✔✔The report sent from the third-party payer to the
provider that reflects any changes made to the original billing.
, ✔✔2 Pieces of Information that need to be collected from patients - ✔✔Patients name
and date of birth
✔✔Deductible - ✔✔Amount you must pay out of pocket before you begin receiving any
benefits from your insurance company
✔✔Coinsurance - ✔✔Pre established percentage of expenses paid by the insurance
company after the deductible has been met
✔✔Copayment - ✔✔A fixed dollar amount that must be paid each time a patient visits a
provider.
✔✔Coordination of Benefit rules - ✔✔Determines which insurance plan is primary and
which is secondary
✔✔Importance of verifying insurance information - ✔✔Important to make sure that the
insurances valid and the services are covered benefits
✔✔Birthday Rule - ✔✔Parent whose birthday comes 1st in the calendar year is
considered primary
✔✔Third Party Payer - ✔✔Organization other than a patient who pays for services, such
as insurance companies, Medicare, and Medicaid.
✔✔Medicare Part A - ✔✔hospitalization coverage
✔✔Medicare Part B - ✔✔Voluntary supplemental medical insurance to help pay for
physicians and other medical professionals services and medical surgical supplies
✔✔Medicare Part D - ✔✔Pays for medications
✔✔Medicare Advantage - ✔✔Combined package of benefits under Medicare Parts A &
B that may offer extra coverage for services such a, vision, hearing, dental, health and
wellness, or prescription coverage.
✔✔Medigap - ✔✔Private health insurance that pays for most of the charges not
covered parts A& B
✔✔Referral - ✔✔Written recommendation to a specialist
✔✔Precertification - ✔✔A review that looks at whether the procedure could be
performed safely but less expensively in an outpatient setting.
✔✔predetermination - ✔✔A written request for a verification of benefits.
EXAM QUESTIONS AND ANSWERS RATED A+
✔✔What is the Difference between Fraud and abuse? - ✔✔Fraud is intentionally
misrepresenting services rendered for the purpose if receiving a higher payment. Abuse
refers to practices that are often done unknowingly as a result of poor business
practices, directly or indirectly resulting in unnecessary costs to the program through
improper payments.
✔✔What is the main job of the office inspector general?(OIG) - ✔✔Protects Medicare
and other HHS programs from fraud and abuse by conducting audits, investigations,
and inspections
✔✔Timely filing requirment - ✔✔Within 1 Calendar year of a claims date
✔✔Electronic data interchange (EDI) - ✔✔The transfer of electronic information in a
standard format
✔✔Coordination of benefits rule - ✔✔Determines which insurance plan is primary and
which is secondary insurance .
✔✔Conditional Payment - ✔✔Medicare payment that is recovered after primary
insurance pays.
✔✔Crossover claim - ✔✔Claim submitted by people covered by primary and secondary
insurance plan
✔✔Two causes of a claim transmission errors - ✔✔Missing or invalid patient
identification number and lack of authorization or referral number
✔✔Assignment of Benefits - ✔✔Contract in which the provider directly bills the payer
and accepts the allowable charge.
✔✔Clean claim - ✔✔Claim that is accurate and complete
✔✔Dirty claim - ✔✔Claim that inaccurate, incomplete, or contains other errors
✔✔Medicare administrative Contractor (MAC) - ✔✔Processes Medicare Parts A & B
claims from hospitals, physicians, and other providers
✔✔Remittance Advice (RA) - ✔✔The report sent from the third-party payer to the
provider that reflects any changes made to the original billing.
, ✔✔2 Pieces of Information that need to be collected from patients - ✔✔Patients name
and date of birth
✔✔Deductible - ✔✔Amount you must pay out of pocket before you begin receiving any
benefits from your insurance company
✔✔Coinsurance - ✔✔Pre established percentage of expenses paid by the insurance
company after the deductible has been met
✔✔Copayment - ✔✔A fixed dollar amount that must be paid each time a patient visits a
provider.
✔✔Coordination of Benefit rules - ✔✔Determines which insurance plan is primary and
which is secondary
✔✔Importance of verifying insurance information - ✔✔Important to make sure that the
insurances valid and the services are covered benefits
✔✔Birthday Rule - ✔✔Parent whose birthday comes 1st in the calendar year is
considered primary
✔✔Third Party Payer - ✔✔Organization other than a patient who pays for services, such
as insurance companies, Medicare, and Medicaid.
✔✔Medicare Part A - ✔✔hospitalization coverage
✔✔Medicare Part B - ✔✔Voluntary supplemental medical insurance to help pay for
physicians and other medical professionals services and medical surgical supplies
✔✔Medicare Part D - ✔✔Pays for medications
✔✔Medicare Advantage - ✔✔Combined package of benefits under Medicare Parts A &
B that may offer extra coverage for services such a, vision, hearing, dental, health and
wellness, or prescription coverage.
✔✔Medigap - ✔✔Private health insurance that pays for most of the charges not
covered parts A& B
✔✔Referral - ✔✔Written recommendation to a specialist
✔✔Precertification - ✔✔A review that looks at whether the procedure could be
performed safely but less expensively in an outpatient setting.
✔✔predetermination - ✔✔A written request for a verification of benefits.
