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Joe and Mary are a married couple and both carry insurance from their employers. Joe was born
on February 23, 1977 and Mary was born on April 4, 1974. 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 date of birth is the 4th and Joe's date of birth 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: D. Joe, because his birth month and day are before Mary's birth month and day.
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
V. Capitation
A. II
B. IV
C. II and IV
D. II, III, and V Correct Answer: C. II and IV
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: C. $900
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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 if he accepts assignment.
D. The claim is not paid because the provider is not participating in the plan. Correct Answer:
A. The payment is sent to the patient and the patient must pay the provider.
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: B. TRICARE Prime A
Medicare card will list which of the following:
I. Effective date of coverage
II. Home address
III. Telephone Number
IV. Entitled to Part A and/or Part B
V. When coverage ends
VI. Name of Primary Care Physician
A. I - VI
B. I, IV
C. I-III, VI
D. I, II, IV, V Correct Answer: B. I, IV
In which of the following scenarios is Medicare the secondary payer?
I. A 65 year-old patient who is collecting her deceased spouse's Medicare benefits and has a
supplemental insurance
II. A 72 year-old patient who participates in the group health insurance of his employer
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III. A 66 year-old patient is injured at work and the employer does not offer health insurance as
a benefit of employment
IV. A 55 year-old patient who is on disability through Social Security and qualifies for
Medicaid and Medicare
A. I-IV
B. II and III
C. I and IV
D. None Correct Answer: B. II and III
When a patient has Medicare primary and AARP as Medigap, what is entered on the CMS-1500
claim form in item 9d for the Insurance Plan Name or Program Name for Medicare to cross
over the claim?
A. Plan name followed by "MEDIGAP"
B. Plan Payer ID followed by "MEDIGAP"
C. COBA Medigap claim-based identifier (ID)
D. Leave blank Correct Answer: C. COBA Medigap claim-based identifier (ID)
Which guidelines must all billing personnel be knowledgeable about in order to ensure
compliance with Medicaid programs?
A. Federal guidelines
B. State guidelines
C. Both A and B
D. None Correct Answer: C. Both A and B
Which of the following services is covered by Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT)?
A. Family planning
B. Obstetric care
C. Pediatric checkups
D. Emergency department visits Correct Answer: C. Pediatric checkups
A female patient who was involved in an auto accident presents to the emergency department
(ED) for evaluation. She does not have any complaints. The provider evaluates her and
determines there are no injuries. The provider informs the patient to come back to the ED or see
her primary care physician if she develops any symptoms. How is the claim processed for this
encounter?
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A. The medical insurance is billed primary and the auto insurance is billed secondary.
B. The auto insurance is billed primary and the medical insurance is billed secondary.
C. Bill the medical insurance first to receive a denial and then submit with the remittance
advice to the auto insurance.
D. Bill only the medical insurance because the auto insurance only covers damage to the
vehicle, not medical expenses. Correct Answer: B. The auto insurance is billed primary and the
medical insurance is billed secondary.
What forms need to be submitted when billing for a work-related injury?
A. Progress reports, and WC-1500 claim form
B. UB-04
C. First Report of Injury form and an itemized statement
D. First Report of Injury form, progress reports, and CMS-1500 claim form Correct Answer:
D. First Report of Injury form, progress reports, and CMS-1500 claim form
A document provided to Medicare patients explaining their financial responsibility if Medicare
denies a service is a(n):
A. Notice of Financial Liability
B. Advance Beneficiary Notice
C. Insurance waiver
D. Explanation of Benefits Correct Answer: B. Advance Beneficiary Notice What is an
Accountable Care Organization (ACO)?
A. Groups of doctors, hospitals, and other health care providers who coordinate
high quality care to Medicare patients.
B. An insurance carrier that provides a set fee based on the diagnosis of the patient.
C. A group of providers who contract with a third party administrator to pay fee for service for
services.
D. Hospitals who see a subset of patients for cost efficiency. Correct Answer: A. Groups of
doctors, hospitals, and other health care providers who coordinate high quality care to
Medicare patients.
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Joe and Mary are a married couple and both carry insurance from their employers. Joe was born
on February 23, 1977 and Mary was born on April 4, 1974. 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 date of birth is the 4th and Joe's date of birth 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: D. Joe, because his birth month and day are before Mary's birth month and day.
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
V. Capitation
A. II
B. IV
C. II and IV
D. II, III, and V Correct Answer: C. II and IV
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: C. $900
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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 if he accepts assignment.
D. The claim is not paid because the provider is not participating in the plan. Correct Answer:
A. The payment is sent to the patient and the patient must pay the provider.
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: B. TRICARE Prime A
Medicare card will list which of the following:
I. Effective date of coverage
II. Home address
III. Telephone Number
IV. Entitled to Part A and/or Part B
V. When coverage ends
VI. Name of Primary Care Physician
A. I - VI
B. I, IV
C. I-III, VI
D. I, II, IV, V Correct Answer: B. I, IV
In which of the following scenarios is Medicare the secondary payer?
I. A 65 year-old patient who is collecting her deceased spouse's Medicare benefits and has a
supplemental insurance
II. A 72 year-old patient who participates in the group health insurance of his employer
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III. A 66 year-old patient is injured at work and the employer does not offer health insurance as
a benefit of employment
IV. A 55 year-old patient who is on disability through Social Security and qualifies for
Medicaid and Medicare
A. I-IV
B. II and III
C. I and IV
D. None Correct Answer: B. II and III
When a patient has Medicare primary and AARP as Medigap, what is entered on the CMS-1500
claim form in item 9d for the Insurance Plan Name or Program Name for Medicare to cross
over the claim?
A. Plan name followed by "MEDIGAP"
B. Plan Payer ID followed by "MEDIGAP"
C. COBA Medigap claim-based identifier (ID)
D. Leave blank Correct Answer: C. COBA Medigap claim-based identifier (ID)
Which guidelines must all billing personnel be knowledgeable about in order to ensure
compliance with Medicaid programs?
A. Federal guidelines
B. State guidelines
C. Both A and B
D. None Correct Answer: C. Both A and B
Which of the following services is covered by Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT)?
A. Family planning
B. Obstetric care
C. Pediatric checkups
D. Emergency department visits Correct Answer: C. Pediatric checkups
A female patient who was involved in an auto accident presents to the emergency department
(ED) for evaluation. She does not have any complaints. The provider evaluates her and
determines there are no injuries. The provider informs the patient to come back to the ED or see
her primary care physician if she develops any symptoms. How is the claim processed for this
encounter?
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A. The medical insurance is billed primary and the auto insurance is billed secondary.
B. The auto insurance is billed primary and the medical insurance is billed secondary.
C. Bill the medical insurance first to receive a denial and then submit with the remittance
advice to the auto insurance.
D. Bill only the medical insurance because the auto insurance only covers damage to the
vehicle, not medical expenses. Correct Answer: B. The auto insurance is billed primary and the
medical insurance is billed secondary.
What forms need to be submitted when billing for a work-related injury?
A. Progress reports, and WC-1500 claim form
B. UB-04
C. First Report of Injury form and an itemized statement
D. First Report of Injury form, progress reports, and CMS-1500 claim form Correct Answer:
D. First Report of Injury form, progress reports, and CMS-1500 claim form
A document provided to Medicare patients explaining their financial responsibility if Medicare
denies a service is a(n):
A. Notice of Financial Liability
B. Advance Beneficiary Notice
C. Insurance waiver
D. Explanation of Benefits Correct Answer: B. Advance Beneficiary Notice What is an
Accountable Care Organization (ACO)?
A. Groups of doctors, hospitals, and other health care providers who coordinate
high quality care to Medicare patients.
B. An insurance carrier that provides a set fee based on the diagnosis of the patient.
C. A group of providers who contract with a third party administrator to pay fee for service for
services.
D. Hospitals who see a subset of patients for cost efficiency. Correct Answer: A. Groups of
doctors, hospitals, and other health care providers who coordinate high quality care to
Medicare patients.
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