CBCS - Certified Billing and Coding Specialist Billing and Claims Submission 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?

Accepted Answer

CMS-1500

Answer

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?

Accepted Answer

Rejected

Answer

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?

Accepted Answer

It will be denied for exceeding the timely filing limit.

Answer

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?

Accepted Answer

Type 2 (Organization)

Answer

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?

Accepted Answer

The mother's plan, because her birthday occurs earlier in the calendar year.

Answer

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.

(CBCS) Certified Billing and Coding Specialist Practice Test

(CBCS) Certified Billing and Coding Specialist Practice Test

CBCS - Certified Billing and Coding Specialist Billing and Claims Submission Questions and Answers