CPB PRACTICE EXAM 79 FULL SOLUTION
STUDY GUIDE
◉ Timely filing requirements are determined by:
Answer: The payer
◉ A denial is received in the office indicating that a service that was
billed is denied due to bundling issues. The medical record is
obtained and, upon review, it is documented that the second
procedure is a staged procedure that was planned at the time of the
initial procedure. When the claim is reviewed, no modifier was
attached to the codes on the claim. What should be done to resolve
the claim?
Answer: Add modifier 58 to the procedure and follow the payer's
guidelines for appeals
◉ What type of denial is more likely to happen when the patient is
insured through an HMO (Health Maintenance Organization)?
Answer: No referral
◉ What is the first step in the majority of denial cases, that you
should take?
Answer: Call the insurance company and find out why the claim is
being denied.
,◉ In what box on the CMS-1500 form does a PA number get placed?
Answer: Box 23
◉ A participating provider of BCBS sees a patient in the ER. The
charges equal $500. The patient has a $1000 deductible of which
none has been met, and a $75 ER copay, How much should be
collected from the patient for this service?
Answer: $75
◉ What is Out-of-pocket?
Answer: The amount of money you need to pay out of pocket
*before* insurance will pay at 100%.
◉ To determine the Medicare coverage and payment policy for a
service or procedure, which resources will indicate if a service or
procedure is payable, non-covered, or bundled into another service?
Answer: Status codes
◉ A Medicare patient is seen by a participating provider. A claim is
sent for $123 and an EOMB is received that states the approved
amount is $100. If the patient has met their deductible, what should
the reimbursement on this claim be from Medicare?
Answer: $80
,◉ Should an ABN be signed before or after services are performed
on Medicare patients?
Answer: Before
◉ What is Medicaids standard timely filing limit?
Answer: There is no standard limit, it is based on the individuals
states timely filing required requirements.
◉ Medicaid agencies are required to report EPSDT performance
information how often?
Answer: Annually
◉ When Medigap is purchased to supplement a person's Medicare
benefits, what entity will the client pay their monthly premium to?
Answer: The Medigap insurer
◉ When Medicare transfers claim information to a Medigap insurer,
what is this called?
Answer: Cross-Over
◉ Is Medicaid Federal or State ran?
Answer: State ran
, ◉ What modifiers are used when an ABN has been signed?
Answer: GA, GX, GY, GZ
◉ When a provider opts out of Medicare, what must they have with
a patient who is a medicare beneficiary prior to providing serviceS?
Answer: A private contract
◉ What are two ways that non-covered service denials can be
decreased in a practice
Answer: -verify coverage before a major service
-understand policies of largest payer contracts
◉ Medicare statutorily excluded services are
Answer: -non-covered items and services
-not reimbursed by Medicare
◉ To determine the Medicare coverage and payment policy for a
service or procedure, which of the following resources will indicate
if a service or procedure is payable, noncovered, or bundled into
another service
Answer: status codes
STUDY GUIDE
◉ Timely filing requirements are determined by:
Answer: The payer
◉ A denial is received in the office indicating that a service that was
billed is denied due to bundling issues. The medical record is
obtained and, upon review, it is documented that the second
procedure is a staged procedure that was planned at the time of the
initial procedure. When the claim is reviewed, no modifier was
attached to the codes on the claim. What should be done to resolve
the claim?
Answer: Add modifier 58 to the procedure and follow the payer's
guidelines for appeals
◉ What type of denial is more likely to happen when the patient is
insured through an HMO (Health Maintenance Organization)?
Answer: No referral
◉ What is the first step in the majority of denial cases, that you
should take?
Answer: Call the insurance company and find out why the claim is
being denied.
,◉ In what box on the CMS-1500 form does a PA number get placed?
Answer: Box 23
◉ A participating provider of BCBS sees a patient in the ER. The
charges equal $500. The patient has a $1000 deductible of which
none has been met, and a $75 ER copay, How much should be
collected from the patient for this service?
Answer: $75
◉ What is Out-of-pocket?
Answer: The amount of money you need to pay out of pocket
*before* insurance will pay at 100%.
◉ To determine the Medicare coverage and payment policy for a
service or procedure, which resources will indicate if a service or
procedure is payable, non-covered, or bundled into another service?
Answer: Status codes
◉ A Medicare patient is seen by a participating provider. A claim is
sent for $123 and an EOMB is received that states the approved
amount is $100. If the patient has met their deductible, what should
the reimbursement on this claim be from Medicare?
Answer: $80
,◉ Should an ABN be signed before or after services are performed
on Medicare patients?
Answer: Before
◉ What is Medicaids standard timely filing limit?
Answer: There is no standard limit, it is based on the individuals
states timely filing required requirements.
◉ Medicaid agencies are required to report EPSDT performance
information how often?
Answer: Annually
◉ When Medigap is purchased to supplement a person's Medicare
benefits, what entity will the client pay their monthly premium to?
Answer: The Medigap insurer
◉ When Medicare transfers claim information to a Medigap insurer,
what is this called?
Answer: Cross-Over
◉ Is Medicaid Federal or State ran?
Answer: State ran
, ◉ What modifiers are used when an ABN has been signed?
Answer: GA, GX, GY, GZ
◉ When a provider opts out of Medicare, what must they have with
a patient who is a medicare beneficiary prior to providing serviceS?
Answer: A private contract
◉ What are two ways that non-covered service denials can be
decreased in a practice
Answer: -verify coverage before a major service
-understand policies of largest payer contracts
◉ Medicare statutorily excluded services are
Answer: -non-covered items and services
-not reimbursed by Medicare
◉ To determine the Medicare coverage and payment policy for a
service or procedure, which of the following resources will indicate
if a service or procedure is payable, noncovered, or bundled into
another service
Answer: status codes
