AAPC CPB Final exam passed solution questions and answers 2024-2025 | Exams Nursing | Docsity (2024)

Download AAPC CPB Final exam passed solution questions and answers 2024-2025 and more Exams Nursing in PDF only on Docsity! AAPC CPB Final exam passed solution questions and answers 2024-2025 Health plan, clearinghouses, and any entity transmitting health information is considered by the Privacy Rule to be a: - answer is covered entity Which of the following is not a covered entity in the Privacy Rule - answer is healthcare consulting firm 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 for release of information is provided. What action should be taken? - answer is release reqt to ins co How many national priority purposes under the Privacy Rules for disclosure of specific PHI without an individual's authorization or permission? - answer is 12 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? - answer is no 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? - answer is Truth in Lending Act Which of the following situations allows release of PHI without authorization from the patient? - answer is workers comp misusing any information on the claim, charging excessively for services or supplies, billing for services not medically necessary, failure to maintain adequate medical or financial records, improper billing practices, or billing Medicare patients at a higher fee scale that non-Medicare patients. - answer is abuse A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS? - answer is abuse According to the Privacy Rule, what health information may not be de-identified? - answer is phys provider number making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal healthcare program - answer is fraud All the following are considered Fraud, EXCEPT: - answer is inadequate med recd 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 to 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? - answer is breach impermissible release or disclosure of information is discovered - answer is breach What standard transactions is NOT included in EDI and adopted under HIPAA? - answer is waiver of liability Insurance coverage provided by an organization that is not an employer (such as a membership organization or credit card company that offer benefits to its members) is what kind of group insurance? - answer is association group office bills Medicare, but the patient receives the payment and the office must collect their fee from the patient. The office, by state law, can charge the patient a limiting charge that is 10 percent above the Medicare fee schedule amount. What type of Medicare provider is this physician? - answer is non par A patient presenting for care does not have an insurance card and is billed CPT 99213 for $100. The patient pays $100 to the provider. A week later, the patient presents verification of coverage through Medicaid for this date of service. What process should be followed? - answer is file a claim to Medicaid w EOB Medicare part without a monthly charge if worked for 10+ years - answer is A Managed Care Organizations (MCOs) place the physician at financial risk for the care of the patient and are reimbursed by - answer is capitation Which of the following is NOT evaluated in the credentialing process? - answer is phys req for priviledges HSA is ____________________ to employees - answer is tax free income What type of plan allows an insurer to administer straight indemnity insurance, an HMO, or a PPO insurance plans to its members? - answer is triple option A healthcare organization with 2 hospitals, 20 clinics, and 3 urgent care centers belongs to an ACO program. They have been in the shared savings program for two years and are now eligible to move large payments to a population-based model as they have been successful in keeping costs down and have met all the CMS benchmarks set for them. What type of ACO is this? - answer is Pioneer What is the largest health program in the United States? - answer is Medicare a unique 10-digit identification number required by HIPAA - answer is NPI Medicaid plans provide for low-income families. Which statement regarding Medicaid is NOT correct? - answer is All plans offer HMOs A new physician comes in to the practice that is just out of medical school. He will need to be able to see patients in the office and at the hospital. What process will he need to undergo in order to be able to participate with Medicare and other health plans? - answer is credentialling NPI numbers have two types of entities - identify the two types: - answer is group and sole proprietor NPI - answer is National Provider Identifier Which of the following services is NOT covered under Medicare Part B? - answer is Home Health ACOs are formed with ___ lives - answer is 5000 HMOs are formed with ___ lives - answer is 100,000 + When insurance coverage is being verified, which of the following is NOT a method on which to rely? - answer is patient When a fee ticket (encounter form) is not completed, what procedure would NOT be acceptable? - answer is no charge Information about deductibles, copays, eligibility dates, and benefit plans is completed during what step? - answer is verify benefits determine primary and secondary coverage - answer is birthday rule Which of the following is NOT considered a part of the authorized process when the patient signs the consent for payment? - answer is auth for treatment Patient types help to classify the patients based on - answer is payer, ins type Life Cycle of a Claim - answer is submission processing adjudication payment/denial What authorizes information to be sent to the insurance payer so payment of medical benefits can be processed? - answer is consent for payment Amount of expenses that must be paid before any payment is made by the insurance company - answer is deductible BCBS member #: - answer is 3 letters then 9 numbers When charges are entered and all required components are verified by the claims editing system, what would this be considered as? - answer is clean claim An E/M service that is performed during a post-operative period, but is not related to the surgical procedure that was performed, can be billed with which modifier? - answer is 24 Medicare provides a list of questions to ask beneficiaries that helps determine if Medicare is primary or secondary. Where can this information be found? - answer is MSP Manual What type of code reports the event(s) related to the billing period on the UB-04 claim form? - answer is occurrence codes What is the purpose of the standard CMS-1500 claim form? - answer is pro services for phys FL 35 and FL 36 are used on the UB-04 claim form to identify occurrence span code and dates. When is this section completed? - answer is inpt services When entering the patient's name on the CMS-1500 claim form, what punctuation should be used? - answer is comma A ___ is used to indicate an inpatient service is reported on an outpatient claim. - answer is condition code The UB-04 claim form is also called: - answer is CMS 1450 Determination of the insurer's payment amount after the member's insurance benefits have been applied. - answer is adjudication ___ provider with overall responsibility for the patient's medical care during hospitalization. - answer is attending Identify the correct format to enter the date of birth on a paper CMS-1500 claim form - answer is MMDDCCYY On the UB-04 claim form, the type of bill is identified by a four-digit numerical code. The first digit is a leading zero, what does the second digit represent? - answer is facility type Medicare refers to the insured's ID as the: - answer is health ins claim number The provider accepts a contractual write-off of the difference between the charged amount and the allowed amount. - answer is accepting assignment Which regulation established claim standards for electronic filing requirements when a provider uses a computer with software to submit an electronic claim? - answer is HIPAA Which is NOT used for data entry? - answer is intl audit sys ________ is when the provider has limited access to payer and patient data elements on their patients only. - answer is extranet When a batch of claims is submitted electronically to a clearinghouse a report is sent to the provider. Which feedback does this report from the clearinghouse identify? - answer is claims sent to payer/rejected A hospital chargemaster does NOT contain which of the following? - answer is ICD10CM codes Which of the following documentation is NOT needed for an audit? - answer is EOB Payments due from patients, payers, or other guarantors that are owed to the practice for services rendered are considered - answer is Accounts Receivable sent by payers to identify the status of a claim and indicate if that claim has been accepted, adjudicated, and/or received by the payer. - answer is status reports A ____________ is a listing of every single procedure that a hospital can provide to its patients that are billed to payers. - answer is chargemaster Converts nonstandard data received from payers to standard transaction data to meet HIPAA requirements - answer is clearinghouse The __________ determines the amount the hospital will be reimbursed for inpatient services if the patient is covered by Medicare. - answer is MSDRGS MS-DRGs - answer is Medicare Severity Diagnosis Related Groups When an adjudication process has been finalized, the payer will send the remittance advice (RA) to? - answer is provider A ______ indicates the location or type of service provided for an inpatient and is reported with _______. - answer is revenue code 4 digit code A fee schedule can be based on - answer is RVUs Which method is the most common to calculate a fee schedule for physicians? - answer is cost based fee schedule An audit that occurs before a claim is submitted is a _____________. - answer is pre payment audit Beth has purchased a Medigap policy to supplement her Medicare coverage. She has authorized Medicare to send payments directly to the physician, and Medicare has transferred their claims information to the Medigap insurance company. This transfer of information is known as: - answer is cross over Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is a program associated with - answer is Medicaid Which of the following are mandatory benefits that must be provided by Medicaid programs in order to receive matching federal funding. - answer is outpt, home, inpt, fed qual health services agree to accept the fee schedules determined by the insurance company. - answer is participating providers Blue Cross/Blue Shield identifies the individual who is eligible for covered services as the: - answer is member Jared is employed with the United States Internal Revenue Service and has enrolled in the Blue Cross/Blue Shield healthcare insurance offered through this employer. What is the name of the Blue Cross/Blue Shield insurance program offered by the federal government? - answer is FEP (Federal Employee Program) The process of reviewing and validating professional qualifications of healthcare providers applying to participate with an organization is known as: - answer is credentialing Carl has enrolled in a healthcare insurance plan that allows him to choose to have services provided within the Blue Cross/Blue Shield network or outside of the network. What type of plan best describes Carl's insurance coverage? - answer is pt of service Not allowed under a participating provider's contract. - answer is balance billing A savings account that allows individuals to save pre-tax dollars to reimburse for healthcare expenses is known as a(n): - answer is FSA, HSA Obtaining approval from the insurance payer before a procedure is performed is known as: - answer is prior auth timely filing restrictions are determined by: - answer is payer Blue Cross/Blue Shield identifies the individual or employer who pays for healthcare insurance coverage as the: - answer is subscriber If a claim is denied, investigated, and found to be denied in error, what should a biller do? - answer is appeal 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 Aetna's policy, what must the biller do? - answer is submit a reconsideration Under what Federal Act must insurance companies implement effective to appeals processes? - answer is pt protection and affordable care act Which of the following can be appealed regarding a claim? - answer is coordination of benefits According to Cigna's appeals process, how many level of internal appeals are offered? - answer is 11 According to Aetna's published guidelines, what is the timeframe for filing an appeal? - answer is 60 days A patient is involved in an accident at work and their commercial insurance is billed. What type of denial will be received? - answer is liability issue When the Cigna appeals process has been exhausted, what happens if the provider still disagrees with the decision? - answer is arbitration 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 Aetna's policy, what must the biller do? - answer is submit reconsideration OSHA is an agency of _______________? - answer is dept of labor Which form is used to submit claims to workers' compensation insurance? - answer is CMS 1500 Who is NOT entitled to Workers' Compensation Benefits? - answer is ind contractor Which program provides lump-sum compensation and health benefits for eligible Department of Energy nuclear weapons workers injured on the job? - answer is Energy Employees Occupational Illness Compensation Program According to OSHA, which industries have the most more work related injuries and illnesses than any other sector? - answer is healthcare and social assistance What type of plan covers private and public employers and acts as an agent in state workers' compensation cases involving state employees? - answer is state ins fund Which program provides workers' compensation benefits to most waterfront workers and contractors working overseas for the U.S. government? - answer is Longshore and Harbor Workers' Compensation Program An example of a non-mid level provider - answer is resident accounts receivable that cannot be collected by the provider or a collection agency. - answer is bad debt Prompt payment act requires clean claims be paid/denied within ___ of receipt - answer is 30 days non participants in Medicare who see a Medicare patient can bill ___% of Medicare fee schedule - answer is 115 accounts that have not been paid within a certain time frame and should be turned over to a collection agency - answer is deliquent Not included in hospital chargemaster - answer is diagnosis codes CMS reuires to file this with claims - answer is routing slip, superbill, encounter form, charge slip CRNA service, without medical direction by a physician - answer is QZ CMS develops LCD's when there is no NCD - answer is False Tricare that is most similar to an HMO - answer is Prime CMS preceding to insurer ID on line 9a - answer is Medigap, MG CPT and HCPSCS Level II code(s) on UB-04 are translated into ___ code for Medicare reimbursem*nt - answer is APC E/M service not recognized by Medicare - answer is consultation codes daily deposits mean balancing ___ receipts - answer is mail, personal payment When a physician does not accept Medicare and pt elects to go anyway. Medicare will send pt the limiting charge for the services provided in order for them to pay most of their bill - answer is unassigned