RMA Insurance and Reimbursement 2 — Questions and Answers
Question 1: A patient has both Medicare and Medicaid. Which is considered the primary payer?
- Medicaid
- Medicare (Correct answer)
- Whichever pays faster
- The patient pays first
Correct answer: Medicare
Medicaid is always the payer of last resort, so Medicare pays first.
Question 2: What does the term 'coordination of benefits' (COB) refer to?
- Bundling multiple procedures into one code
- Determining the order in which multiple insurers pay (Correct answer)
- Coordinating appointments between providers
- Combining deductibles across plans
Correct answer: Determining the order in which multiple insurers pay
COB establishes which insurer is primary and which is secondary when a patient has more than one plan.
Question 3: Under the 'birthday rule,' which parent's plan is primary for a dependent child?
- The older parent's plan
- The parent whose birthday falls earlier in the calendar year (Correct answer)
- The parent with the higher income
- The mother's plan always
Correct answer: The parent whose birthday falls earlier in the calendar year
The birthday rule makes primary the plan of the parent whose birthday comes first in the year.
Question 4: What is an Explanation of Benefits (EOB)?
- A bill sent to the patient
- A statement from the insurer detailing what was paid and patient responsibility (Correct answer)
- A referral authorization form
- A list of covered medications
Correct answer: A statement from the insurer detailing what was paid and patient responsibility
The EOB documents the insurer's processing of a claim, including payments and patient responsibility.
Question 5: A 'capitation' payment model reimburses a provider how?
- Per service rendered
- A fixed amount per patient per month regardless of services (Correct answer)
- Based on diagnosis severity
- Only after the deductible is met
Correct answer: A fixed amount per patient per month regardless of services
Capitation pays a set fee per enrolled patient per period, no matter how many services are used.
Question 6: Which form is the standard claim form used for physician and outpatient services?
- UB-04
- CMS-1500 (Correct answer)
- CMS-1450
- ADA Dental Claim
Correct answer: CMS-1500
The CMS-1500 is the standard paper claim form for physician and non-institutional outpatient services.
Question 7: What is 'usual, customary, and reasonable' (UCR) charge?
- The amount the provider always bills
- A fee within the range commonly charged for a service in a geographic area (Correct answer)
- The Medicare-set rate
- The patient's out-of-pocket maximum
Correct answer: A fee within the range commonly charged for a service in a geographic area
UCR reflects the typical fee charged for a service within a specific region.
RMA Insurance and Reimbursement 2
A patient has both Medicare and Medicaid.
Which is considered the primary payer?