AAPC Claims Management & Adjudication 3

Question 1

Which National Uniform Claim Committee (NUCC) form is used by professional providers to submit paper claims?

Accepted Answer

CMS-1500

Answer

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?

Accepted Answer

Charges exceed the fee schedule/maximum allowable amount

Answer

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?

Accepted Answer

The payer requires additional information before making a payment determination

Answer

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?

Accepted Answer

To uniquely identify the healthcare provider submitting or rendering the service

Answer

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?

Accepted Answer

The patient's Medicare cost-sharing (copay/deductible) up to the Medicaid allowed amount

Answer

Medicaid as secondary payer typically covers cost-sharing amounts left by Medicare, but only up to the Medicaid fee schedule amount.

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