CPCA CPCA Reimbursement and Payer Policies 2 — Questions and Answers
Question 1: What form is used to submit professional claims to Medicare and most commercial payers?
- UB-04
- CMS-1500 (Correct answer)
- CMS-1450
- ADA Dental Claim Form
Correct answer: CMS-1500
The CMS-1500 is the standard paper claim form used by physicians and other non-institutional providers.
Question 2: A patient has both Medicare Part B and a Medigap policy. Which payer receives the claim first?
- Medigap
- Medicare Part B (Correct answer)
- Medicaid
- The patient pays first
Correct answer: Medicare Part B
Medicare Part B is always the primary payer, and the Medigap policy is billed as secondary for the remaining balance.
Question 3: What does the term 'coordination of benefits' (COB) refer to in medical billing?
- Calculating the patient's deductible
- Determining which payer is primary when a patient has multiple coverages (Correct answer)
- Verifying provider credentials with insurance companies
- Submitting claims electronically
Correct answer: Determining which payer is primary when a patient has multiple coverages
COB is the process used to prevent duplicate payment when a patient has more than one health insurance plan.
Question 4: Which modifier is appended to a CPT code to indicate that a service was reduced or eliminated at the physician's discretion?
- Modifier 52 (Correct answer)
- Modifier 25
- Modifier 59
- Modifier 51
Correct answer: Modifier 52
Modifier 52 is used when a service or procedure is partially reduced, signaling to the payer that full reimbursement is not expected.
Question 5: A practice receives a denial code CO-4. What does this typically indicate?
- Service not covered by the plan
- Modifier is inconsistent with the procedure code (Correct answer)
- Duplicate claim submitted
- Patient is not eligible
Correct answer: Modifier is inconsistent with the procedure code
CO-4 indicates the service code is inconsistent with the modifier, requiring the biller to review the modifier-procedure pairing.
Question 6: What is the timely filing limit for most commercial insurance claims if not otherwise specified?
- 30 days from date of service
- 90 days from date of service
- 1 year from date of service (Correct answer)
- 6 months from date of service
Correct answer: 1 year from date of service
Most commercial payers and Medicare require claims to be filed within 1 year (12 months) of the date of service.
CPCA CPCA Reimbursement and Payer Policies 2
What form is used to submit professional claims to Medicare and most commercial payers?