AAPC Claims Management & Adjudication 3 — Questions and Answers
Question 1: Which National Uniform Claim Committee (NUCC) form is used by professional providers to submit paper claims?
- UB-04
- CMS-1450
- CMS-1500 (Correct answer)
- ADA Dental Claim Form
Correct answer: CMS-1500
The CMS-1500 form is the standard paper claim form used by physicians and other professional providers.
Question 2: A payer issues an Explanation of Benefits (EOB) showing 'CO-45.' What does this adjustment reason code mean?
- Charges exceed the fee schedule/maximum allowable amount (Correct answer)
- Claim submitted after the timely filing deadline
- Duplicate claim submitted
- Service not covered by plan
Correct answer: Charges exceed the fee schedule/maximum allowable amount
CO-45 indicates the charge exceeds the contracted fee schedule or maximum allowable, and the difference is a contractual write-off.
Question 3: When a claim is marked 'pending' during adjudication, what does this typically indicate?
- The claim has been fully paid
- The payer requires additional information before making a payment determination (Correct answer)
- The patient has reached their out-of-pocket maximum
- The provider is suspended from the network
Correct answer: The payer requires additional information before making a payment determination
A pending status means the payer has suspended the claim awaiting additional information, documentation, or internal review.
Question 4: What is the purpose of the National Provider Identifier (NPI) on a claim?
- To identify the patient's primary diagnosis
- To uniquely identify the healthcare provider submitting or rendering the service (Correct answer)
- To indicate the tax identification number for reimbursement
- To specify the insurance plan type
Correct answer: To uniquely identify the healthcare provider submitting or rendering the service
The NPI is a unique 10-digit identifier assigned to healthcare providers under HIPAA for use in standard transactions including claims.
Question 5: A patient has Medicare as primary and Medicaid as secondary. After Medicare pays, what does Medicaid typically cover?
- The full Medicare-allowed amount
- The patient's Medicare cost-sharing (copay/deductible) up to the Medicaid allowed amount (Correct answer)
- Only services not covered by Medicare
- The entire billed amount minus Medicare payment
Correct answer: The patient's Medicare cost-sharing (copay/deductible) up to the Medicaid allowed amount
Medicaid as secondary payer typically covers cost-sharing amounts left by Medicare, but only up to the Medicaid fee schedule amount.
Question 6: Which of the following is an example of a 'clean claim'?
- A claim missing the subscriber's date of birth
- A claim with all required data elements properly completed and no known deficiencies (Correct answer)
- A claim submitted after the timely filing period
- A claim with an invalid diagnosis code
Correct answer: A claim with all required data elements properly completed and no known deficiencies
A clean claim contains all required information and has no deficiencies that would prevent or delay payment processing.
Question 7: What does 'subrogation' mean in the context of medical claims?
- The process of bundling multiple services on one claim
- An insurer's right to recover payment from a third party responsible for the patient's injury (Correct answer)
- Retroactive adjustment of previously paid claims
- Transfer of billing responsibility from provider to patient
Correct answer: An insurer's right to recover payment from a third party responsible for the patient's injury
Subrogation allows an insurer that paid a claim to seek reimbursement from the party legally responsible for causing the patient's injury.
AAPC Claims Management & Adjudication 3
Which National Uniform Claim Committee (NUCC) form is used by professional providers to submit paper claims?