CPCA Reimbursement and Payer Policies Flashcards
6 cards from real CPCA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CPCA Reimbursement and Payer Policies flashcards as text
What form is used to submit professional claims to Medicare and most commercial payers?
Answer: CMS-1500
The CMS-1500 is the standard paper claim form used by physicians and other non-institutional providers.
A patient has both Medicare Part B and a Medigap policy. Which payer receives the claim first?
Answer: Medicare Part B
Medicare Part B is always the primary payer, and the Medigap policy is billed as secondary for the remaining balance.
What does the term 'coordination of benefits' (COB) refer to in medical billing?
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.
Which modifier is appended to a CPT code to indicate that a service was reduced or eliminated at the physician's discretion?
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.
A practice receives a denial code CO-4. What does this typically indicate?
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.
What is the timely filing limit for most commercial insurance claims if not otherwise specified?
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.