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.
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 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
1 \/ 4
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
2 \/ 4
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)
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 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 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. 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 Answer- D.
First Report of Injury form, progress reports, and CMS-1500 claim form
3 \/ 4
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 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. 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 Answer- A. Bill under the PA.
CPT\u00ae 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\u00ae 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. 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<\/p>\n","protected":false},"excerpt":{"rendered":"
Joe and Mary are a married couple and both carry insurance from their employers. Joewas born on February 23, 1977 and Mary was born on April 4, 1974. Using the birthdayrule, 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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-113172","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/113172","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=113172"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/113172\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=113172"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=113172"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=113172"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}