Specialty Certified Medical Assistant Medical Office Administration and Billing 1 — Questions and Answers
Question 1: What is the purpose of an Explanation of Benefits (EOB) document?
- A bill sent directly to the patient for unpaid services
- A statement from the insurance company explaining what was paid, denied, or applied to deductible (Correct answer)
- A list of covered services under a health plan
- A referral document from the primary care physician
Correct answer: A statement from the insurance company explaining what was paid, denied, or applied to deductible
An EOB explains how the insurance company processed a claim, including amounts paid, adjustments, patient responsibility, and denial reasons.
Question 2: What coding system is used to classify diagnoses in medical billing?
- CPT codes
- ICD-10-CM codes (Correct answer)
- HCPCS codes
- NPI codes
Correct answer: ICD-10-CM codes
ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) codes are used to classify and report diagnoses on medical claims.
Question 3: What is a copayment in health insurance?
- The total amount the patient pays for health insurance premiums annually
- A fixed dollar amount the patient pays at the time of service (Correct answer)
- The percentage of costs the patient pays after meeting the deductible
- The maximum out-of-pocket expense for the year
Correct answer: A fixed dollar amount the patient pays at the time of service
A copayment (copay) is a fixed dollar amount paid by the patient at the time of service, regardless of the total cost of care.
Question 4: Which form is used to submit claims to Medicare for professional services?
- UB-04 form
- CMS-1500 form (Correct answer)
- UB-92 form
- ADA Dental Claim form
Correct answer: CMS-1500 form
The CMS-1500 is the standard claim form used by individual providers and outpatient facilities to bill Medicare, Medicaid, and many private insurers.
Question 5: What does 'prior authorization' mean in medical billing?
- Approval from the patient before treatment
- Approval from the insurance company before certain services are provided (Correct answer)
- A physician's written order for a procedure
- Pre-certification of the medical office by the state
Correct answer: Approval from the insurance company before certain services are provided
Prior authorization is pre-approval from the insurance payer confirming that a specific service, medication, or procedure will be covered before it is performed.
Question 6: What is the difference between a deductible and coinsurance?
- Both are the same concept described differently
- A deductible is the amount paid before insurance begins; coinsurance is the percentage paid after the deductible is met (Correct answer)
- Coinsurance is paid before insurance begins; the deductible is a fixed copay
- The deductible applies only to hospitalization; coinsurance applies to outpatient care
Correct answer: A deductible is the amount paid before insurance begins; coinsurance is the percentage paid after the deductible is met
The deductible is the annual out-of-pocket amount before insurance pays; coinsurance is the percentage of costs shared between patient and insurer after the deductible.
Specialty Certified Medical Assistant Medical Office Administration and Billing 1
What is the purpose of an Explanation of Benefits (EOB) document?