AAPC CPB Test Bank Questions With Complete Solutions 2022 Graded A, Exams of Nursing

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AAPC CPB Test Bank Questions

With Complete Solutions 2022|

GRADED A

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. $ B. $ C. $ D. $1,600 Correct Answer: C. $

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

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?

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- 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- 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.

A new patient presents for her annual exam and has no complaints. She is scheduled to see the physician assistant (PA). How should services be billed? A. Bill under the PA. B. A new patient can be billed incident to the physician. C. The PA cannot see new patients. D. Reschedule the patient with the physician Correct Answer: A. Bill under the PA. CPT® codes 12032 and 12001 were reported together for a 2.6 cm intermediate repair of a laceration to the right arm and a 2.5 cm simple repair of a laceration to the left arm. 12001 was denied as a bundled service. What action should be taken by the biller (following the CPT® guidelines)? A. Write-off the charge for 12001 as it is a bundled procedure. B. Resubmit a corrected claim as 12032, 12001-59. C. Transfer the charge to patient responsibility. D. Resubmit a corrected claim as 12032, 12001-51. Correct Answer: B. Resubmit a corrected claim as 12032, 12001-59. According to CMS, which of the following services are included in the global package for surgical procedures? I. Surgical procedure performed II. E/M visits unrelated to the diagnosis for which the surgical procedure is performed III. Local infiltration, digital block, or topical anesthesia IV. Treatment for postoperative complication which requires a return trip to the operating room (OR)V. Writing Orders VI. Postoperative infection treated in the office A. I, III, V, VI B. I, IV, V C. I, II, III, V D. I-VI Correct Answer: A. I, III, V, VI Which CPT® code below can be reported with modifier 51? A. 17004 B. 17312

C. 19101

D. 19126 Correct Answer: C. 19101 A HCPCS/CPT® code is assigned "1" in the MUE file. What does this indicate? A. Code pairs cannot be reported together. B. Codes can be reported together if documented. Append modifier 59. C. The code can only be reported for one unit of service on a single date of service. D. Medically unlikely the code pair is performed together. Correct Answer: C. The code can only be reported for one unit of service on a single date of service. Electronic Healthcare Transactions and code sets are required to be used by health plans, healthcare clearinghouses and healthcare providers that participate in electronic data interchanges. Which of the following are requirements for the code sets? I. Dental services are reported with CDT codes II. Inpatient procedures are reported with HCPCS Level II codes III. Diagnosis codes are reported with ICD-10-CM and ICD-10-PCS codes IV. Outpatient services are reported with CPT® and HCPCS Level II codes V. Physician services are reported with ICD-10-PCS codes A. I and IV B. II, III, and V C. II, III, and IV D. II and IV Correct Answer: A. I and IV Which of the following indicates the frequency of care on a UB-04 claim form? A. Revenue code B. Type of Bill C. MSDRG D. Condition code Correct Answer: B. Type of Bill Pam works for a medical practice. She discovered a claim was overpaid by Medicare. What Act requires the money to be refunded? A. Health Insurance Portability and Accountability Act B. The Stark Act C. False Claims Act

D. Consumer Credit Protection Act Correct Answer: C. False Claims Act Security involves the safekeeping of patient information by: I. Setting office policies to protect PHI from alteration, destruction, tampering, or loss II. Allowing full access to all employees to the electronic medical records III. Giving employees a policy on confidentiality to read IV. Requiring employees to sign a confidentiality statement that details the consequences of not maintaining patient confidentiality, including termination A. I and IV B. I, II, and IV C. II, III, and IV D. II and III Correct Answer: A. I and IV Dr. Taylor's office has a new medical assistant (MA) who is responsible for blood collection for lab specimens. Because the MA is new, she often misses when obtaining blood on the first stick. To be sure the office is billing for all services, the office now has a rule that all patients will be billed a minimum of two blood draws to demonstrate the work that is being done for lab collection. Which statement is true regarding this rule? A. The rule covers the office and allows them to get paid for all services performed. B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error. C. The rule would be legal if changed to only bill for two blood draws on the patients the MA misses on the first stick. D. The rule is only legal if the clinic is in a hospital-based office. Correct Answer: B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error. An example of an overpayment that must be refunded is? A. Payment based on a reasonable charge. B. An unprocessed voided claim. C. Incorrect posting of an EOB. D. Duplicate processing of a claim Correct Answer: D. Duplicate processing of a claim

Which of the following is true regarding provider credentialing? A. A provider can complete an application with CAQH which handles credentialing for many payers. B. A provider is required to complete the credentialing process with private payers before an NPI application can be submitted. C. A provider can complete an application with NCQA to credential with private payers and obtain an NPI. D. Approval of the NPI number is all the provider needs to be credentialed with all payers. Correct Answer: A. A provider can complete an application with CAQH which handles credentialing for many payers. Which Act protects information collected by consumer reporting agencies? A. Equal Credit Opportunity Act B. Fair Credit Reporting Act C. Fair Debt Collection Practices Act D. Truth in Lending Act Correct Answer: B. Fair Credit Reporting Act There is a written office policy to write off patients co-insurance and copayment amounts as a professional courtesy. Is this appropriate? A. Yes, if it is a policy in writing it must be followed. B. Yes, if it is a written policy and everyone in the office adheres to it. C. No, it is considered fraud to write off the patients' responsibility for all patients. D. No, it is a violation of Stark law to write off patients' responsibility. Correct Answer: C. No, it is considered fraud to write off the patients' responsibility for all patients. Which statement is TRUE regarding the Fair Debt Collection Practices Act (FDCPA)? A. Collectors are allowed to threaten legal action even if it will not be pursued. B. The FDPCA does not apply to medical practices. C. Collectors are allowed to contact debtors repeatedly. D. Collectors are not allowed to contact debtors at odd hours. Correct Answer: D. Collectors are not allowed to contact debtors at odd hours.

Which of the following is an allowed collection policy after a patient files for bankruptcy? A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected. B. Any co-payments or deductibles that are past due and owed by the patient can be collected. C. Unpaid claims for dates of service occurring before the date of the bankruptcy and any co-pays or deductibles adjudicated on that same claim. D. Discuss a payment arrangement with the patient to settle the past due account. Correct Answer: A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected. A patient with an acute myocardial infarction is brought by ambulance to the emergency department. The patient is taken into the cardiac catheterization lab. Angioplasty and a stent was placed in the LAD. The patient's insurance requires preauthorization for all surgical procedures. Which of the following statements is true for most payers? A. If the biller did not obtain authorization prior to the procedure being performed, the surgical services will not be paid. B. Because this was an emergency, it is acceptable to obtain authorization following the surgery. C. Because this was an emergency, a preauthorization is not required. D. If the biller did not obtain authorization prior to the procedure being performed, the entire claim will not be paid. Correct Answer: B. Because this was an emergency, it is acceptable to obtain authorization following the surgery. Which of the following steps should be completed when filling an appeal? I. Submit in the format required by the payer. II. Review the reason for the denial and determine if the payer made an error. III. Provide supporting documentation from an official source to support your reason for appeal. IV. Keep a copy of the information submitted to the payer for the appeal. V.Appeal the claim as soon as a denial is received. VI. Appeal the claim as soon as you are certain the payer denied in error and the claim cannot be reprocessed. A. I, II, and V

B. I, IV, V and VI C. I, II, III, IV, and VI D. I-VI Correct Answer: C. I, II, III, IV, and VI What should a biller do when a claim is denied for not being submitted within the timely filing period? A. Track the transmission date of the claim. If within the timely filing period, provide the information to the payer to reprocess the claim. B. Write off the claim. The patient is not responsible for claims denied for not being submitted within the timely filing period. C. Resubmit the claim with a different date of service that is within the timely filing period. D. Transfer the balance to patient responsibility and try to collect from the patient. Correct Answer: A. Track the transmission date of the claim. If within the timely filing period, provide the information to the payer to reprocess the claim. Incorrect entry of the patient demographics can have an effect on many areas of the practice. What documents are necessary to verify demographics? I. Photo Identification II. Insurance card III. Credit card information IV. Social Security card V. Patient completed demographic form A. I and V B. II and IV C. II, IV and V D. I, II, and V Correct Answer: D. I, II, and V CMS has a standard enrollment form in which the provider agrees to: I. Submit claims to Medicare II. Have authorization from the Medicare beneficiary to file claims III. Retain all source documentation and medical records IV. Submit claims within 60 days of the date of service V. Submit all claims with a group NPI number VI. Research and correct claim discrepancies.

A. I, II, and IV B. II, IV, and V C. I, III, IV, and VI D. I, II, III, and VI Correct Answer: D. I, II, III, and VI Ms. Turner had surgery one month ago for hernia repair. She is still in the post- operative period and comes in today to the see the same physician that performed the hernia repair surgery about a lump that she noticed on her tailbone. The physician performs an examination and the diagnosis is that she has a pilonidal cyst which is unrelated to the surgery. Can the physician bill an E/M service for today's visit during the post-operative period? A. Yes, the E/M service can be reported with modifier 24 to indicate it is unrelated to the surgery. B. No, because the examination falls in the post-operative period of the original procedure. C. No, report code 99024 instead of the E/M service for all services provided in the post-operative period. D. Yes, the E/M can be reported with modifier 25 to indicate a separate procedure or service was performed. Correct Answer: A. Yes, the E/M service can be reported with modifier 24 to indicate it is unrelated to the surgery. When you respond to a patient with "How may I help you, Mrs. Jones?", the use of the patient's name: A. Is too familiar B. Violates HIPAA C. Indicates to the caller you are interested and listening D. Is too formal for an existing patient Correct Answer: C. Indicates to the caller you are interested and listening A dermatologist performed an excision of a squamous cell carcinoma from the patients forehead with a 1.2 cm excised diameter. The excision site required an intermediate wound closure measuring 1.8 cm. What is/are the correct code(s)? A. 11642 B. 11442 C. 11642, 12051- D. 11442, 12051-51 Correct Answer: C. 11642, 12051-

55-year-old female presents to the office with ongoing history of type I diabetes which has been controlled with insulin. During the exam the physician notes that gangrene has set in due to the diabetic peripheral angiopathy on her left great toe. Patient is recommended to see a general surgeon for treatment of the gangrene on her left great toe. A. I96, E10.9, Z79. B. E11.52, I96, Z79. C. E10. D. I96, E11.52 Correct Answer: C. E10. What is the correct HCPCS Level II code for Depo-Provera (medroxyprogesterone acetate) injection of 100 mg? A. J B. J1050 x 100 C. J1020 x 5 D. J1030 x 3 Correct Answer: B. J1050 x 100 The provider performs an office visit with an expanded problem focused history, expanded problem focused exam and low MDM to manage the patient's hypertension. The provider also destroys two plantar warts. How is this reported? A. 99213-25, 17110 B. 99213-25, 17110- C. 99213, 17110- D. 99213, 17110-59 Correct Answer: A. 99213-25, 17110 HMO plans require the enrollee to: Correct Answer: To have referrals to see a specialist that is generated by the patient's PCP What are PPOs (preferred provider organizations)? Correct Answer: Organizations in which medical professionals and facilities provide services to subscribed clients at reduced rates. What is a covered entity? Correct Answer: Health plans, clearinghouses, and any entity transmitting health information is considered to be as is stated by the Privacy Rule.

What are the three steps to be taken when there is a breach of contract between a covered entity and a business associate? Correct Answer: 1. Take steps to correct or end the violation

2. Terminate the contract
3. Report the breach to HHS A request for medical records is received for a specific date of service from patient's insurance company with regards to a submitted claim. No authorization or release of information is provided. What action should be taken? Correct Answer: Release the requested records to the insurance company. Can you release PHI without authorization from a patient if it is for a workers' compensation claim? Correct Answer: Yes, Workers compensation information is not protected under HIPAA HIPAA mandated what entity to adopt national standards for electronic transactions and code sets? Correct Answer: HHS What is the standard time frame established for record retention? Correct Answer: There is no single standard record retention time frame. It varies by state and federal regulation. CMS defines as billing for a lower level of care than is supported in documentation, making false statements to obtain undeserved benefits or payment from a federal healthcare program, or billing for services that were not performed. Correct Answer: Fraud A claim is submitted for a patient on medicare with a higher fee schedule that a patient on Insurance ABC. What is this considered under CMS? Correct Answer: Abuse A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statue? Correct Answer: FCA (False claims act) What act is "upcoding or unbundling services" considered under? Correct Answer: The false claims act

A practice sets up a payment plan with a patient. If more than four installments are extended to the patient, what regulation is the practice subject to that makes the practice a creditor? Correct Answer: TILA (truth in lending act) A patient is seen in your clinic. Her husband calls later in the day to ask for information about the visit. The practice pulls the patients privacy authorization to see if they can speak to the husband. What act does this action fall under? Correct Answer: HIPAA Medicare was passed into law under what Act? Correct Answer: SSA Are healthcare regulations the same in each state? Correct Answer: No, they will vary from state to state. A physician's office (covered entity) discovers that the billing company (Business associate) is in breach of their contract. What is the first steps to be taken. Correct Answer: Take steps to correct the problem and end the violation. OIG, CMS, and the DOJ are the government agencies enforcing what laws? Correct Answer: Federal fraud and abuse laws Do fraud and abuse penalties include the ability to refile claims in question? Correct Answer: No A biller at a medical practice notices that all claims contain CPT code 81002. She questions the nurse who tells her that because they are an OB/Gyn office, they bull every patient for a urinalysis. What does this violate? Correct Answer: FCA Medical records are requested for a patient for a specific date of service. When records are copied, multiple dates of service are copied and sent in reply to the request. What standard does this violate? Correct Answer: Minimum necessary Individuals have the right to review and obtain copies of the PHI. What is excluded from rights of access? Correct Answer: - Psychotherapy notes

• Certain lab results
• Information involved in research studies
• Information related to legal proceedings Patient questions and concerns regarding the Privacy Practices in the clinic should be addressed by what party? Correct Answer: The Privacy official

How many standard EDI transactions were adopted under HIPAA? Correct Answer: 8 What are the standard EDI transactions adopted under HIPAA? Correct Answer: 1. Claims and encounter info

2. Payment and remittance advice
3. Claim status
4. Eligibility for a health plan
5. Enroll / Dis-enrollment in a health plan
6. Referrals and authorizations
7. COB
8. Premium payments In addition to the standardization of the codes what other identifier is used on all claims? Correct Answer: A unique identifier for employers and providers The federal false claims act allows for claims to be reviewed for how many years after an incident? Correct Answer: Seven years Entities that have been identified as having improper billing practices are defined by CMS as a violation of what standard? Correct Answer: Abuse What penalties can be imposed for Fraud and / or abuse related to the US code? Correct Answer: Monetary penalties ranging from $10k to $50k (before inflation) for each item or service, imprisonment, and exclusion from federal healthcare programs. How long after being identified should a practice return medicare over payments? (days) Correct Answer: 60 days A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered? Correct Answer: A covered entity According to the privacy rule, what health information may not be de-identified? Correct Answer: The physician provider number A hospital records transporter is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box on the street. It is

discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this? Correct Answer: A breach A practice allows patients to pay large balances over a six month time period with a finance charge applied. The patient receives a statement every month that only shows the unpaid balance. What does this violate? Correct Answer: TILA When a practice sends an electronic claim to a commercial health plan for payment, what is this considered? Correct Answer: A transaction While working in a large practice, medicare over-payments are found in several patient accounts. The manager states that the practice will keep the money until medicare asks for it back. What does this action constitute? Correct Answer: Fraud What were the eight standard EDI transactions adopted under? Correct Answer: HIPAA A practice agrees to pay $250k to settle a lawsuit alleging that the practice used x- rays of one patient to justify services on multiple other patient's claims. That manager of the office brought the civil suit. What type of case is this? Correct Answer: Qui Tam A health plan sends a request for medical records in order to adjudicate a claim. Does the office have to notify the patient or have them sign a release to send the information? Correct Answer: No, since the information is used for payment activities it is not necessary to notify or obtain authorization (reference: TPO) Fraud or Abuse: A clinic fails to maintain adequate medical records Correct Answer: Abuse Fraud or Abuse: A clinic bills every new patient at the highest level E/M visit no matter what Correct Answer: Fraud Fraud or Abuse: A clinic is found to be falsifying documentation to support a service that was billed to receive payment Correct Answer: Fraud Fraud or Abuse: Reporting a diagnosis code that the patient does not have, but is payable by medicare. Correct Answer: Fraud

According to the privacy rule, what must a business associate and covered entity have in order to do business? Correct Answer: A contract If a provider is excluded from federal health plans, what does that mean? Correct Answer: They many not participate in Medicare, Medicaid, VA programs, or Tricare and They cannot bill for services or provide services, order services, or prescribe medication to any beneficiary of a federal plan. What is the purpose of the privacy rule? Correct Answer: To protect patient privacy A records request is received from a health plan for three dates of service in a chart months apart. What should the biller do? Correct Answer: Copy each date of service individually and send to the health plan. Is a healthcare consulting firm considered a covered entity? Correct Answer: No A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every medicare patient you send them for radiology services. What does this offer violate? Correct Answer: The Anti-kickback law How many national priority purposes are under the Privacy rule to disclose PHI without an individuals authorization? Correct Answer: 12 What are the 12 national priority purposes under the privacy rule? Correct Answer:

1. Required by law
2. Public health activities
3. Victims of abuse / neglect/ domestic violence
4. Health oversight activities
5. Judicial and administrative proceedings
6. Law enforcement purposes
7. decedents
8. cadaver organ / eye / tissue donation
9. Research
10. Serious threat to health or safety
11. Essential government functions
12. Workers comp. What types of entities doe conditions of participation apply to for health plans? Correct Answer: Hospitals, clinics, transplant centers, psychiatric hospitals, etc

What is the key term that distinguishes fraud from abuse? Correct Answer: "knowingly" Federal agencies are required to pay clean claims within how many days? Correct Answer: 30 What is the prompt payment act? Correct Answer: An act that was enacted to ensure the federal government makes timely payments. When accepting debit cars in a medical practice, which act requires the office to disclose information before completing a transaction? Correct Answer: The electronic funds transfer act A claim has been denied as not medically necessary by medicare. The biller has checked the patient's medical record and the patient's insurance policy. No ABN was signed. What is the next action the biller should take? Correct Answer: Write off the charge or check with the provider to appeal the claim. A provider removes a skin lesion in an ASC and receives the denial from the insurance carrier that states "Lower level of care could have been provided." What steps should the biller take? Correct Answer: Check with the provider and write an appeal to the insurance carrier explaining why the service was provided in an ASC. A claim was resubmitted to AAPC Insurance Company through a clearinghouse 60 days after the date of service and the claim was denied. AAPC Insurance Plan has a 60 day timely filing limit. The biller checked the claim status system and determined AAPC Insurance Plan did not receive the claim. What action should the biller take? Correct Answer: Check the clearinghouse' report and appeal the denial with proof of claim submission What is the definition of bad debt? Correct Answer: A debt that is likely to remain unpaid and end up sent to collections and written off by the provider. What does a high number of days in A/R indicate for a medical practice? Correct Answer: The practice potentially has a problem in the revenue cycle. What should be included in a financial policy? Correct Answer: - Explanation that patient balances are due at the time services are provided

• List of insurance carriers the providers are contracted with

• List of the practice's policy when seeing patients who are out of network. How often should insurance coverage verification happen? Correct Answer: at each visit What are some potential patient errors that can happen at patient registration? Correct Answer: Invalid address, invalid insurance info, invalid phone number What is the best way to ask a patient about their demographic information? Correct Answer: By asking open ended questions When a provider want to give a discount on services to a patient, what must they do prior to billing the insurance carrier? Correct Answer: The provider must discount the charge prior to billing insurance What is a prompt payment discount? Correct Answer: A discount given to self pay patient when they pay at the time of service Which Act protects information collected by the consumer reporting agencies? Correct Answer: The fair credit reporting act If a medical office receives notice that a patient has filed for bankruptcy, what steps should be taken? Correct Answer: -obtain the case number -verify the case filing -verify the provider is listed as a creditor -stop all collection efforts for balances filed under the bankruptcy What is the number one thing you should obtain from an insurance call? Correct Answer: The call reference number When given a denial, what should be done? Correct Answer: Review the denial to determine if additional information is needed, if errors need to be corrected, or if the denial should be appealed When should patient invoices be sent to the patient? Correct Answer: As soon as the RA is posted and the balance has been transferred to the patient account. May small balances for which processing costs exceed potential collections be automatically written off? Correct Answer: Yes, as long as it is allowed according to the financial policy of the practice.

What documents are needed for a successful appeal? Correct Answer: -Copy of the RA -Copy of the medical record -Copy of the original claim

• A letter detailing why the claim should be paid A biller received a request for medical records for Patient A for DOS 05/15/20XX. Patient A's entire medical record (multiple dates of service) was copied and sent to the insurance carrier. What is this a violation of? Correct Answer: HIPAA Once a credit balance for an insurance carrier has been identified, what action should the biller take? Correct Answer: Research to determine if it is a true overpayment, the submit a refund to the insurance carrier for the overpayment. What a patient files for Chapter 7 under the U.S. bankruptcy code, what happens to the debt? Correct Answer: Most medical debt is discharged, the provider will write-off amounts owed. Which chapter of U.S. Bankruptcy combines the debt of the debtor and reduces the monthly payments allowing the provider to potentially receive a portion of what is owed? Correct Answer: Chapter 13 According to the Prompt Pay Act, who must pay bills within 30 days? Correct Answer: Federal Agencies What is a prior authorization? Correct Answer: A requirement that your physician receives approval form your heath insurance plan to approve payment for a specific service for you What is a pre-determination? Correct Answer: A request from a healthcare facility to get an idea whether or not a service may be covered. This is not a guarantee of payment and is not required. The provider, hospital, or entity that agrees to provide healthcare services to an insurance plans enrolees is a: Correct Answer: Participating provider What is the process of determining which of two or more insurance policies will have the primary responsibility of processing a claim? Correct Answer: Coordination of benefits

Balance billing by participating providers is: Correct Answer: Not allowed under participating providers contract Claim rejections are due to what? Correct Answer: Claims that do not contain necessary information for adjudication What information can be found on the BCBS insurance identification card? Correct Answer: -Type of plan -ID number -Group number -phone number for member services/benefits questions -mailing address of the BCBS office According to aetna's published guidelines what is the time frame for filing a reconsideration? Correct Answer: Within 180 calendar days of the initial claim decision A BCBS insurance plan that allows members to choose any provider but offers higher levels of coverage when members obtain services from network providers would be an example of: Correct Answer: PPO If a claim is denied, investigated, or found to be denied in error what should a biller do? Correct Answer: Appeal that claim Carl has enrolled in a healthcare insurance plan that allows him to choose to have services provided within the BCBS network or outside of the network what type of plan best describes Carl's coverage Correct Answer: POS What is the limit called what payrs allow to submit a claim or appeal? Correct Answer: Timely filing Jerod is employed with the US IRS and has enrolled in the BCBS healthcare insurance offered through his employer, what is the name of the BCBS insurance program offered by the federal government? Correct Answer: FEP(Federal Employee Program) What may be appealed? Correct Answer: A denied claim

A savings account that allows individuals to save pre tax dollars to reimburse for healthcare expenses is known as an: Correct Answer: FSA and HSA What modifiers will appropriately bypass the NCCI bundling edits? Correct Answer: 25, 58 Tony's BCBS insurance policy states that he must seek healthcare services only from providers that are part of a specific network what type of BCBS does Tony have? Correct Answer: HMO BCBS identifies the individual who pays for healthcare insurance coverage as the: Correct Answer: subscriber What can be done in the practice to ensure liability denials will not be received? Correct Answer: Perform thorough intake on patients that present with injuries BCBS identifies the individual who is eligible for covered services as the: Correct Answer: Member Under what federal act must insurance companies implement effective appeals processes? Correct Answer: The patient protection and affordable care act BCBS received a claim on 4/15/14 for services performed on 3/15/13 the claim would be denied because: Correct Answer: The claim was filed after the timely filing limit Submitting a secondary claim without a primary insurance EOB is what kind of issue? Correct Answer: COB The process of reviewing and validating professional qualifications of healthcare providers applying to participate with an organization is known as: Correct Answer: Credentialing An initial denial is received in the office from Aetna, the denial is investigated and the office considers that the payment was not according to their contract. According to Aenta's policy what must the biller do? Correct Answer: Resubmit a reconsideration Participating providers agree to: Correct Answer: Accept the fee schedules determined by the insurance company

What is "Medically necessary" Correct Answer: Services appropriate to the evaluation and treatment of a disease condition illness or injury and consistent with the applicable standard of care What information can be found on an EOB Correct Answer: What rejections/Denials are mostly preventable with good front office policy? Correct Answer: Incorrect patient information, eligibility expiration, and liability denials Timely filing requirements are determined by: Correct Answer: The payer The best practice to prevent a non-covered service denial would be to: Correct Answer: Determine if the procedure is covered prior to providing the service 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? Correct 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? Correct Answer: No referral Best practice to prevent receiving a denial due to coverage termination would be to: Correct Answer: Verify coverage prior to the patient's scheduled appointment. What is the first step in the majority of denial cases, that you should take? Correct Answer: Call the insurance company and find out why the claim is being denied. The liaison between BCBS and the contracted provider community is known as what? Correct Answer: The insurance representative. Also known as the provider representative or the provider network consultant. In what box on the CMS-1500 form does a PA number get placed? Correct Answer: Box 23

A health insurance plan that reimburses for healthcare services provided to members based on providers bills submitted after the services are rendered is known as: Correct Answer: Traditional insurance. Also known as Fee-for-service, or an indemnity plan. What is the difference between non-covered services and not medically necessary services? Correct Answer: Non-covered services are pre-determined to not be re- reimbursable by the insurance while not-medically necessary services have been found to not be necessary for the evaluation and treatment of an individuals disease, condition, illness, or injury. When a patient presents for their appointment, insurance coverage should be verified and: Correct Answer: A copy should be made of both the front and back of the member's insurance card. For which denial is it acceptable to balance bill the patient? Correct Answer: Non- covered service BCBS offers which type of Medicare plan? Correct Answer: A medicare advantage plan (part C) 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? Correct Answer: $75 What is a copay? Correct Answer: A fixed amount of money that you will pay for an office visit same day. What is a deductable? Correct Answer: The amount of money you need to pay for services before insurance will pay anything. What is Co-insurance? Correct Answer: The amount of money you will pay for services after the deductible is met but before you have reached your maximum out of pocket amount. What is Out-of-pocket? Correct Answer: The amount of money you need to pay out of pocket before insurance will pay at 100%. What are the 4 parts of Medicare? Correct Answer: A,B,C,D

What does Medicare A cover? Correct Answer: Hospital services What does Medicare B cover? Correct Answer: Out-patient services What is Medicare C? Correct Answer: This is a Medicare replacement plan for A+B offered by private companies that are contracted with Medicare. AKA a medicare advantage plan. What is Medicare D? Correct Answer: Coverage for prescription medicine A patient receiving inpatient care in a critical access hospital would be covered under which part of Medicare? Correct Answer: Part A For services such as screening for depression, bone mass measurements, and glaucoma screenings, what does Medicate consider these services to be? Correct Answer: Preventative 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? Correct Answer: Status codes Medigap policies must conform to minimum standards identified as federal and state laws and clearly be identified as: Correct Answer: Medicare supplemental insurance Allen who is a non-par provide who doesn't accept assignment performs an appendectomy on a 67 year old Medicare patient. The physician's UCR for the surgery is $1500. Medicare's approved fee for this procedure is $1100. What is the charge that this non-par provider can charge to this Medicare patient? Correct Answer: $1201.75 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? Correct Answer: $80 If a physician opts-out of Medicare and has a private contract with the medicare patient, at what percent of the Medicare fee schedule may they charge the patient for services rendered? Correct Answer: They do not participate with Medicare