CPB Certified Professional Biller

What is the primary purpose of the CMS-1500 claim form in medical billing?

• ATo submit professional/physician service claims to payers
• BTo submit hospital inpatient claims
• CTo report quality measures to CMS
• DTo request prior authorization

Which electronic transaction standard is used for submitting professional claims under HIPAA?

• A837P (Professional)
• B837I (Institutional)
• C835 (Remittance Advice)
• D270/271 (Eligibility)

A patient's insurance company denies a claim with reason code CO-4. What does this denial indicate?

• AThe procedure code is inconsistent with the modifier used or a required modifier is missi…
• BThe service is not covered under the patient's benefit plan
• CThe claim was submitted after the timely filing deadline
• DThe patient has not met the annual deductible

What is the difference between a deductible and a copayment in health insurance?

• AA deductible is the amount the patient must pay before insurance begins to cover services…
• BA deductible and copayment are the same thing
• CA copayment is paid before insurance begins; a deductible is paid per visit
• DNeither applies to professional billing

Which regulation prohibits billing Medicare and the patient for charges above the Medicare-approved amount for participating providers?

• AThe Medicare participation agreement (accepting assignment)
• BThe False Claims Act
• CThe Anti-Kickback Statute
• DThe HIPAA Privacy Rule

What does EOB stand for in medical billing?

• AExplanation of Benefits
• BEstimation of Billing
• CEvidence of Benefits
• DEvaluation of Benefits

When a patient has coverage under two insurance plans, which concept determines the order of payment?

• ACoordination of Benefits (COB)
• BPrior Authorization
• CMedical Necessity Determination
• DUtilization Review

What is the purpose of a prior authorization in medical billing?

• ATo obtain approval from the insurance company before a service is rendered to confirm cov…
• BTo verify the patient's identity
• CTo submit a claim for payment
• DTo appeal a denied claim

Which CMS-1500 form field is used to enter the patient's diagnosis codes?

• ABox 21
• BBox 24D
• CBox 33
• DBox 17

A patient presents with Medicare as primary insurance and a commercial plan as secondary. After Medicare processes the claim, what is the next step?

• ASubmit the remaining balance to the secondary insurance with the Medicare remittance info…
• BBill the patient for the full remaining balance
• CWrite off the remaining balance
• DResubmit the claim to Medicare for additional payment

What is a clean claim in medical billing?

• AA claim that contains all required data elements and can be processed without additional…
• BA claim that has been paid in full
• CA claim submitted on paper rather than electronically
• DA claim that has no diagnosis codes

Which federal law established the HIPAA transaction and code set standards used in medical billing?

• AHealth Insurance Portability and Accountability Act of 1996 (HIPAA)
• BAffordable Care Act (ACA)
• CHITECH Act
• DBalanced Budget Act of 1997

What is the timely filing limit for Medicare claims?

• A12 months (1 calendar year) from the date of service
• B90 days from the date of service
• C180 days from the date of service
• D24 months from the date of service

A claim is denied with the reason 'patient not eligible on date of service.' What is the first step in resolving this denial?

• AVerify the patient's insurance eligibility and coverage dates for the date of service
• BAppeal the denial immediately
• CWrite off the balance
• DRebill the claim with different diagnosis codes

What is the purpose of an ERA (Electronic Remittance Advice) in the billing cycle?

• ATo provide electronic notification of claim payment, adjustment, and denial details from…
• BTo submit claims electronically to payers
• CTo verify patient eligibility before a visit
• DTo request prior authorization for services

Which group code on a remittance advice indicates that the patient is responsible for the adjustment amount?

• APR (Patient Responsibility)
• BCO (Contractual Obligation)
• COA (Other Adjustment)
• DPI (Payer Initiated)