CBCS - Certified Billing and Coding Specialist Billing and Claims Submission Questions and Answers 1 — Questions and Answers
Question 1: A physician's office needs to bill for a routine patient check-up provided in their clinic. Which standard claim form should be used to submit this professional service to the insurance payer?
- UB-04
- CMS-1500 (Correct answer)
- ABN (Advanced Beneficiary Notice)
- CMS-1490S
Correct answer: CMS-1500
The CMS-1500 is the standard claim form used by non-institutional providers, such as physicians in an office setting, to bill for professional services. The UB-04 is used for institutional claims, like those from hospitals or skilled nursing facilities. An ABN is a notice given to a Medicare beneficiary, not a claim form, and the CMS-1490S is a form a patient can use to request Medicare payment.
Question 2: A billing specialist submits a claim electronically. The clearinghouse report indicates the claim was not forwarded to the payer because it contained an invalid patient ID number. What is the status of this claim?
- Rejected (Correct answer)
- Denied
- Pending
- Adjudicated
Correct answer: Rejected
A rejected claim is one that has been stopped by the clearinghouse or payer's front-end system before processing due to errors like invalid data or formatting issues. It must be corrected and resubmitted. A denied claim is one that the payer has processed and deemed unpayable based on coverage or other policies.
Question 3: A medical practice submits a claim for a service rendered on March 10, 2025. The payer's timely filing limit is 180 days from the date of service. The claim is submitted on October 1, 2025. What is the MOST likely outcome for this claim?
- It will be paid in full as submitted.
- It will be rejected by the clearinghouse for a formatting error.
- It will be paid at a reduced rate due to the delay.
- It will be denied for exceeding the timely filing limit. (Correct answer)
Correct answer: It will be denied for exceeding the timely filing limit.
The time between March 10 and October 1 is over 200 days, which exceeds the payer's 180-day timely filing limit. Payers strictly enforce these deadlines, and claims submitted past the allowed timeframe are typically denied for this reason.
Question 4: A large hospital system that employs hundreds of physicians applies for a National Provider Identifier (NPI) to use for billing purposes for the organization itself. Which type of NPI would this entity receive?
- Type 3 (Facility)
- Type 1 (Individual)
- Type 2 (Organization) (Correct answer)
- Group Practice NPI
Correct answer: Type 2 (Organization)
NPIs come in two types. Type 1 NPIs are for individual healthcare providers (e.g., physicians, dentists). Type 2 NPIs are for organizational healthcare providers, such as hospitals, group practices, and nursing homes.
Question 5: A child is covered under health insurance plans from both parents. The mother's birthday is May 20th and the father's birthday is August 5th. According to the "birthday rule," which parent's plan is considered primary for the child's claims?
- The father's plan, because his birthday is later in the year.
- The mother's plan, because her birthday occurs earlier in the calendar year. (Correct answer)
- The plan of the parent who has had coverage for a longer period.
- The plan of the parent whose name comes first alphabetically.
Correct answer: The mother's plan, because her birthday occurs earlier in the calendar year.
The "birthday rule" is a standard method for determining primary vs. secondary coverage for a dependent child. The plan of the parent whose birthday (month and day only) occurs first in the calendar year is primary. Since May comes before August, the mother's plan is primary.
Question 6: When reviewing an Electronic Remittance Advice (ERA), a CBCS notices that a payment for a specific service has been reduced. Which of the following would provide the standardized, specific reason for this payment adjustment?
- Claim Adjustment Reason Code (CARC) (Correct answer)
- CPT Code
- National Provider Identifier (NPI)
- Place of Service (POS) Code
Correct answer: Claim Adjustment Reason Code (CARC)
Claim Adjustment Reason Codes (CARCs) are standard codes used on an ERA or EOB to explain why a claim was paid differently than it was billed. They communicate the reason for any adjustment, reduction, or denial from the payer.
CBCS - Certified Billing and Coding Specialist Billing and Claims Submission Questions and Answers 1
A physician's office needs to bill for a routine patient check-up provided in their clinic.
Which standard claim form should be used to submit this professional service to the insurance payer?