A 6 year-old is seen in the pediatrician office for the first time. He has insurance coverage through both his mother (DOB: 02/08/86 and his father (DOB: 05/15/85). Whose insurance is primary? A. Mother's insurance plan B. Father's insurance plan C. The policy that has the best benefits D. Either mother's or father's insurance plan depending who brings the child in for medical care. Correct Answer: A. Mother's insurance plan Which managed care plan has the patient receiving care from participating providers (network provider) and the providers are only paid for services provided? A. Health Maintenance Organization (HMO) B. Point-of-Service Plan (POS) C. Exclusive Provider Organization (EPO) D. Integrated Delivery System (IDS) Correct Answer: C. Exclusive Provider Organization (EPO) Which TRICARE plan is similar to an HMO plan? A. TRICARE For Life B. TRICARE Select C. TRICARE Prime D. TRICARE Young Adult Correct Answer: C. TRICARE Prime Which of the services are covered by Medicare Part A? I. Skilled Nursing Facility Care II. Ambulatory Surgery III. Durable Medical Equipment IV. Hospice Care V. Home Health Services VI. Long Term Care VII. Outpatient prescription drugs A. I-VII B. II, III, VI C. I, II, IV, VII D. I, IV, V Correct Answer: D. I, IV, V Which is a TRUE statement regarding Workers' Compensation? A. There is no copayment for the injured worker in workers' compensation cases. B. The filing deadline for a first report of injury form is one week from the date of the accident. C. Providers can balance bill a patient when compensation payment is not paid in full. D. There is a deductible for the injured worker in workers' compensation claims. Correct Answer: A. There is no copayment for the injured worker in workers' compensation cases. Bob sees his family physician for seasonal allergies. Before leaving, Bob pays the charge for the office visit. As a courtesy, the physician's staff submits a claim to Bob's insurance company. If the service is covered by the insurance company, Bob can expect to be reimbursed for the office visit. This is which type of insurance model? A. Healthcare Anywhere B. Managed Care Plan C. Fee-for-service (traditional coverage) D. Health Maintenance Organization (HMO) Correct Answer: C. Fee-for-service (traditional coverage) Which of the following benefits are NOT covered by all Medigap policies? I. Part A co-insurance and hospital costs II. Skilled nursing facility care co-insurance III. Parts A & B deductible IV. Part B excess charges V. Foreign travel exchange A. I, II, III B. I, III C. I, IV, V D. II, III, IV, V Correct Answer: D. II, III, IV, V Medicaid eligibility is primarily determined by? A. Income B. Prior insurance coverage C. Marital status D. Number of living relatives Correct Answer: A. Income ____________ is incorporated by CMS into the NCCI program to limit the number of times a service or procedure can be reported by a physician on the same date of service to a patient. A. Outpatient Code Editor (OCE) B. Medically Unlikely Edits (MUE) C. Physician Fee Schedule D. National Coverage Determination (NCD) Correct Answer: B. Medically Unlikely Edits (MUE) In the CPT® codebook, which of the following codes may be used for reporting synchronous telemedicine services when appended by modifier 95? A. 93000 B. 99441 C. 99225 D. 99253 Correct Answer: D. 99253 Which service is NOT included in the global package for surgical procedures? A. Treatment for postoperative complications that require a return trip to the OR. B. Writing orders C. Evaluating the patient in the Post-Anesthesia Care Unit D. Local infiltration, digital block, topical anesthesia Correct Answer: A. Treatment for postoperative complications that require a return trip to the OR. A biller notices there is a large amount of Medigap claims where Medicare has paid the claim but Medicaid has not processed or paid the claim. After research, the biller discovers the IDs for the Medigap coverage is not formatted correctly on the CMS 1500 claim form. Which of the following format is correct for the Medigap insurer ID in Item 9a? A. 675974608 B. AETNA675974608 C. MG675974608 D. Item 9a is left blank Correct Answer: C. MG675974608 When item 18 on a CMS-1500 claim form has dates of service for inpatient care, what is entered in item 32? A. Physician's name and office address who saw the patient in the hospital. B. Patient's name and address. C. Name and address of the facility that provided the service D. You can leave block Item 32 blank because block Item 33 has the required information. Correct Answer: C. Name and address of the facility that provided the service According to CPT® subsection guidelines for Excision-Malignant Lesions, when there is a removal of a 3 cm malignant lesion on the arm and the defect area is repaired with an intermediate layer closure, how is it reported? A. 11603, 12032-51 B. 11603 C. 12032 D. 11603, 12002-51 Correct Answer: A. 11603, 12032-51 On the UB-04 claim form the type of bill (TOB) is reported with four digits. Which digit classifies the type of care provided? A. Digit 1 B. Digit 2 C. Digit 3 D. Digit 4 Correct Answer: C. Digit 3 The CPT® or HCPCS Level II code reported on a UB-04 is translated to what type of code by Medicare to reimburse for outpatient facility services? A. Ambulatory Payment Classification (APC) B. National Drug Code (NDC) C. International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS) D. Both B and C Correct Answer: A. Ambulatory Payment Classification (APC)