CPC Reimbursement & Claims Processing 1 — Questions and Answers
Question 1: Which claim form is used by physicians and outpatient facilities to bill Medicare Part B?
- UB-04 (CMS-1450)
- CMS-1500 (Correct answer)
- ADA Dental Claim Form
- ANSI X12 837P
Correct answer: CMS-1500
The CMS-1500 claim form is the standard paper claim form used by physicians and non-institutional providers to bill Medicare Part B and most commercial insurers.
Question 2: What does the term 'coordination of benefits' (COB) mean in health insurance?
- A process for calculating patient deductibles
- A process to determine which payer pays first when a patient has multiple insurance plans (Correct answer)
- The method used to calculate provider reimbursement rates
- The process of appealing a denied claim
Correct answer: A process to determine which payer pays first when a patient has multiple insurance plans
Coordination of benefits (COB) determines the order in which multiple health insurance plans pay claims so that total payments do not exceed 100% of the claim.
Question 3: What is a 'clean claim' in medical billing?
- A claim with no diagnosis codes
- A claim submitted without errors that can be processed and paid without additional information (Correct answer)
- A claim for preventive services only
- A claim that has been scrubbed of duplicate charges
Correct answer: A claim submitted without errors that can be processed and paid without additional information
A clean claim is one that contains all required information and can be processed for payment without additional follow-up or information from the provider.
Question 4: Which Medicare term describes the amount Medicare has approved for a covered service?
- Allowed amount
- Medicare Fee Schedule amount (Correct answer)
- Charge amount
- Cost-sharing amount
Correct answer: Medicare Fee Schedule amount
The Medicare Fee Schedule amount (approved amount) is the maximum amount Medicare will pay for a covered service based on the Medicare Physician Fee Schedule.
Question 5: What is the timely filing deadline for Medicare Part B claims?
- 90 days from the date of service
- 180 days from the date of service
- One year (12 months) from the date of service (Correct answer)
- Two years from the date of service
Correct answer: One year (12 months) from the date of service
Medicare Part B claims must be filed within one calendar year (12 months) from the date of service to be considered timely.
Question 6: A patient's insurance pays 80% of allowed charges after the deductible is met. The remaining 20% is called the:
- Premium
- Deductible
- Copayment
- Coinsurance (Correct answer)
Correct answer: Coinsurance
Coinsurance is the percentage of the allowed amount the patient pays after meeting the deductible, typically expressed as a percentage like 20%.
CPC Reimbursement & Claims Processing 1
Which claim form is used by physicians and outpatient facilities to bill Medicare Part B?