AAPC CPB CERTIFIED PROFESSIONAL BILLER
EXAM 2026 COMPREHENSIVE STUDY AND
ANSWER GUIDE
◉ 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 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 Answer: C. $900
◉ 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. 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 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 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
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 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 Answer: C. COBA Medigap claim-based identifier (ID)
EXAM 2026 COMPREHENSIVE STUDY AND
ANSWER GUIDE
◉ 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 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 Answer: C. $900
◉ 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. 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 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 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
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 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 Answer: C. COBA Medigap claim-based identifier (ID)
