CPC Reimbursement & Claims Processing 2

Question 1

What is an Explanation of Benefits (EOB)?

Accepted Answer

A statement from the insurer explaining how a claim was processed and paid

Answer

An EOB is a document from the insurance company showing how a claim was adjudicated, including amounts billed, allowed, paid, and patient responsibility.

Question 2

Which type of Medicare denial occurs when a service is not covered under the patient's Medicare benefit?

Accepted Answer

Coverage/benefit denial

Answer

A coverage/benefit denial means the service is not a covered benefit under the patient's Medicare plan, not a medical necessity issue.

Question 3

The Resource-Based Relative Value Scale (RBRVS) used by Medicare is based on which three components?

Accepted Answer

Physician work, practice expense, and malpractice expense

Answer

The RBRVS consists of physician work RVUs, practice expense RVUs, and malpractice expense RVUs, each adjusted by a geographic practice cost index (GPCI).

Question 4

What is the purpose of a Medicare Advance Beneficiary Notice (ABN)?

Accepted Answer

To inform the beneficiary that Medicare may not cover a service and that the patient may be liable

Answer

An ABN is given to Medicare patients before providing a service that may be denied as not medically necessary, informing them they may be financially responsible.

Question 5

In the Medicare reimbursement system, what does 'participating provider' status mean?

Accepted Answer

The provider accepts Medicare's approved amount as payment in full and cannot balance bill

Answer

Participating providers (PAR) accept assignment and agree to accept the Medicare approved amount as payment in full, without balance billing.

(CPC) Certified Procedural Coder Practice Test

(CPC) Certified Procedural Coder Practice Test

CPC Reimbursement & Claims Processing 2