AAPC-CPB Certified Professional Biller - Set 1 - Part 1

Correct Answer: Health insurance issuer

Under the HIPAA definitions, a health insurance issuer is an insurance company, service, or organization, including an HMO, licensed to do insurance business in a State and subject to State insurance law. The term excludes a group health plan. Option a is incorrect because a clearinghouse is a separate covered entity type alongside health plans and providers, and it is not defined by State insurance licensure. Option b is incorrect because the definition of the described term expressly excludes a group health plan, so this term cannot be what the excerpt describes. Option c is incorrect because State health care programs are programs such as State Medicaid and the Children's Health Insurance Program, not licensed insurance organizations.

Correct Answer: Children's Health Insurance Program under Title XXI

OIG guidance defines State health care programs to include State Medicaid programs, the Maternal and Child Health Services Block Grant program, Block Grants to States for Social Services, and the Children's Health Insurance Program under Title XXI. Option b is incorrect because OIG guidance excepts this program from the definition of Federal health care programs, and it does not appear in the list of State health care programs. Option c is incorrect because this is a list OIG maintains of currently excluded individuals and entities, not a health benefit program of any kind. Option d is incorrect because grant fraud liability is an OIG enforcement authority covering misuse of HHS grant funds, so it is a penalty authority rather than a program providing health benefits.

Correct Answer: An unlisted program whose principal activity is making grants for direct care

The HIPAA definition excludes a government-funded program not on the listed plans when its principal activity is the direct provision of health care or making grants to fund that direct provision. Option a is incorrect because the definition names it expressly, under 38 U.S.C. chapter 17, as a health plan, so the exclusion for other government-funded programs does not reach it. Option b is incorrect because it appears in the list of covered health plans under the Indian Health Care Improvement Act, which keeps it outside the government-funded program exclusion. Option d is incorrect because listed under Part C of title XVIII, it is a named health plan, whereas the exclusion applies only to government-funded programs outside the list.

Correct Answer: The plan is not considered a GHP

Medicare's GHP definition requires employees or former employees as enrollees. A plan solely for self-employed agents has none, so it is not a GHP, and Medicare is not secondary to it. Option a is incorrect because self-insured plans are included in the GHP term, but a plan with no employees or former employees as enrollees still fails the definition. Option b is incorrect because the definition turns on who is enrolled, not who set up the plan; an insurer's sponsorship does not create GHP status without employee enrollees. Option c is incorrect because employee-pay-all plans are GHPs under employer or employee organization auspices, which requires employee enrollees; a plan for self-employed agents alone lacks them.

Correct Answer: COBRA is secondary because it arises from COBRA law

For aged or disabled Medicare beneficiaries, COBRA continuation coverage is secondary to Medicare. The coverage exists by virtue of COBRA law rather than by virtue of current employment status, so Medicare pays first. Option a is incorrect because the Medicare manual assigns one order of payment here and describes no equal sharing between continuation coverage and Medicare. Option b is incorrect because that period applies to an ESRD related Medicare beneficiary, and this patient is entitled to Medicare because of age, not ESRD. Option d is incorrect because group health plan status alone does not decide order; for aged beneficiaries the coverage exists by virtue of COBRA law, not current employment status.

Correct Answer: TRICARE coverage

Coverage under TRICARE does not meet the definition of a GHP. Medicare is primary to TRICARE unless the individual is on active duty, whereas union plans, governmental plans and employee-pay-all plans are included in the GHP definition. Option b is incorrect because the definition expressly includes plans under the auspices of employers or employee organizations even when the employer makes no contribution toward the coverage. Option c is incorrect because union plans are named as examples of employee organization plans, which fall within the GHP definition, so Medicare may be secondary to them. Option d is incorrect because plans of governmental entities, whether Federal, State or local, are listed within the term GHP, and this program is the example given.

Correct Answer: At a uniform level

The definition of an MA plan states that its specific set of health benefits is offered at a uniform premium and a uniform level of cost-sharing to all Medicare beneficiaries residing in the plan's service area. Option a is incorrect because cost-sharing is set at the plan level for the whole service area; the definition does not let it vary by individual provider. Option b is incorrect because the MA plan definition ties cost-sharing to the plan's service area, not to beneficiary age, and gives every resident the same level. Option c is incorrect because beneficiaries do not negotiate their own terms; the plan's benefits, premium and cost-sharing are set once and offered identically to residents of the service area.

Correct Answer: Medicare+Choice is a separate program that replaced Part D.

Medicare+Choice is the older name for Medicare Advantage, which operates under Part C. Part D is the voluntary prescription drug benefit program, so a claim that Medicare+Choice replaced Part D is inaccurate. Option b is incorrect because compliance guidance identifies Medicare Advantage organizations by this earlier name, so the link between the two terms is accurate. Option c is incorrect because the regulatory definition of Medicare Part C states exactly this, describing it as a choice of benefits through Medicare Advantage plans under title XVIII. Option d is incorrect because program rules on administration say an individual may keep or obtain other health insurance, expressly including the choice to enroll in a Medicare+Choice plan.

Correct Answer: A region approved by CMS

Under the definition of service area, an MA regional plan's service area is a region approved by CMS, within which an MA-eligible individual may enroll in a particular MA plan offered by an MA organization. Option a is incorrect because counties define the service area of a local MA plan, not a regional plan, which is tied to an approved region. Option c is incorrect because State licensure concerns an MA organization's status as a risk-bearing entity and does not set the geographic area of a regional plan. Option d is incorrect because this is the residence setting for enrollees of a senior housing facility plan, which restricts enrollment rather than setting regional boundaries.

Correct Answer: Federal Hospital Insurance Trust Fund

Part A is financed through separate payroll contributions, and the proceeds are deposited to the account of the Federal Hospital Insurance Trust Fund, which is used only for hospital insurance benefits and administrative expenses. Option a is incorrect because general revenues are appropriated to cover Part A costs for certain non-beneficiaries, so they are not where payroll contribution proceeds are deposited. Option b is incorrect because monthly Social Security benefits are separate from Part A financing; Part A payroll contributions are deposited to a hospital insurance fund instead. Option d is incorrect because it is the separate account that holds Part B premiums and Government contributions, and it pays only Part B benefits and administrative expenses.

Correct Answer: Need for physical therapy

A beneficiary who is confined to the home and under a physician's care can qualify through a need for skilled nursing on an intermittent basis, physical therapy, or speech-language pathology services. Physical therapy therefore establishes entitlement. Option a is incorrect because this was a Part A requirement that has been eliminated, and in any case a past stay is not a service need that creates entitlement. Option b is incorrect because the qualifying nursing need is described as skilled nursing services on an intermittent basis, not continuous care, and this beneficiary has no nursing need. Option c is incorrect because occupational therapy was eliminated as a basis for entitlement; it can only extend eligibility for a person who already qualified on another basis.

Correct Answer: Providing continued treatment after hospitalization

The Medicare manual states that the purpose of the additional benefits, posthospital extended care in SNFs and home health care, is to provide continued treatment after hospitalization and encourage economical alternatives to inpatient hospital care. Option b is incorrect because inpatient hospital days have their own limit, and SNF days are separate and mutually exclusive, so these benefits do not add hospital days. Option c is incorrect because supplementary medical insurance (Part B) is a separate, related program, and the additional Part A benefits are not described as a substitute for it. Option d is incorrect because housekeepers, food service arrangements and transportation to outpatient facilities are expressly excluded from home health services, so they cannot be the purpose.

Correct Answer: I, II, and IV

To obtain SMI, an eligible individual must enroll during an enrollment period and pay premiums. Entitlement to HI confers eligibility, and SMI pays after a yearly cash deductible. Part B cannot pay for services payable under Part A. Option a is incorrect because statement III reverses the rule, since Part B payment may not be made for a service that may be paid under Part A. Option b is incorrect because this pair leaves out statement I, yet entitlement to HI is one recognized route to eligibility to enroll in SMI. Option d is incorrect because adding statement III makes the set wrong, because Part B pays only where Part A payment is not possible, such as exhausted benefits.

Correct Answer: Federal Supplementary Medical Trust Fund

Part B is financed by monthly premiums from voluntary enrollees and by Federal general revenue contributions. All of this money is deposited in a separate account, the Federal Supplementary Medical Trust Fund, used only for Part B benefits and administrative expenses. Option a is incorrect because it receives Part A payroll contributions and appropriations from general revenues, and it is used only for hospital insurance benefits and administrative expenses. Option b is incorrect because Medicare+Choice is a plan option an individual may elect instead of other coverage; the manual describes it as a plan choice, not as a deposit account. Option c is incorrect because Social Security is named in the financing section only as a benefit status that affects who pays the HI portion of FICA, not as a Part B deposit account.

Correct Answer: Diabetes outpatient self-management training services

Medicare Part B lists diabetes outpatient self-management training services among its covered medical and other health services, which fits a beneficiary with diabetes who needs education to manage the condition. Option a is incorrect because these are preventive gynecologic screenings in the covered list, unrelated to training a beneficiary in diabetes self-care. Option b is incorrect because this is a screening service listed for bone health and has no role in teaching a beneficiary to manage diabetes. Option d is incorrect because this covers a drug for dialysis patients who can use it without supervision, so it addresses kidney care, not patient education about diabetes.

Correct Answer: A/B MAC (A) serving the parent provider

For HHAs and hospices based in another Medicare provider such as a hospital or SNF, audit, cost report settlement and other fiscal functions, including interim payment rates, are performed by the A/B MAC (A) serving the parent provider. Option b is incorrect because this contractor enrolls physicians and non-physician practitioners and pays Part B claims for services and supplies, not institutional fiscal functions for a hospital-based agency. Option c is incorrect because the HHH contractor receives the agency's bills and pays them, but audit and settlement for a facility-based agency go to the parent provider's contractor. Option d is incorrect because DME MACs operate in the non-provider Part B program under contract with the Secretary, so they carry no fiscal role for provider-based agencies.

Correct Answer: The patient's physician and the treating facility

The Medicare manual states that the law does not permit federal supervision or control over the practice of medicine, so responsibility for treatment and control of care remains with the individual's physician and the hospital or other facility furnishing services. Option a is incorrect because States hold administrative roles in Medicare, but those roles do not include controlling the practice of medicine or the treatment decisions of an individual's physician. Option b is incorrect because voluntary insurance organizations were given substantial administrative roles because of their insurance experience, which is separate from responsibility for treatment and control of care. Option c is incorrect because the CMS Administrator conducts the program under delegation from the Secretary, and the law bars federal supervision or control over how medical services are provided.

Correct Answer: Certifying to DHHS that providers meet conditions of participation

State agencies, not CMS, certify to DHHS whether providers satisfy, and continue to satisfy, the conditions of participation. CMS handles policy formulation, benefit determinations, operational policy and agreements. Option b is incorrect because the guidance assigns CMS the task of establishing, maintaining and administering agreements with State agencies, providers of services and A/B MACs. Option c is incorrect because CMS is charged with deciding the nature and duration of services for which a beneficiary's benefits may be paid, so this belongs to CMS. Option d is incorrect because the guidance lists this among CMS responsibilities, since CMS sets the operational policy that contractors follow in administering the program.

Correct Answer: Licensed by the State as a risk-bearing entity

Under the Medicare Advantage definitions, an entity licensed or otherwise authorized by the State to assume risk for health insurance or benefits coverage, and so able to accept prepaid capitation under an MA contract, is licensed by the State as a risk-bearing entity. Option a is incorrect because refers to an MA plan providing qualified prescription drug coverage under Part D, which concerns benefit content rather than authority to accept capitation. Option c is incorrect because is a coordinated care plan structured as a PPO serving one or more entire regions; it names a plan structure, not state licensure. Option d is incorrect because describes an MA eligible individual living in the community who requires an institutional level of care, so it classifies a person, not an organization.

Correct Answer: medical assistance furnished under a State plan

The Medicaid third party liability regulation defines a third party as any individual, entity or program that is or may be liable to pay all or part of the expenditures for medical assistance furnished under a State plan. Option a is incorrect because incentive payments are made by the agency to jurisdictions that enforce and collect medical support; they are not the expenditures covered by the third party definition. Option b is incorrect because a private insurer is a separately defined term describing commercial or prepaid plans, and the third party definition refers to medical assistance expenditures, not premiums. Option d is incorrect because title IV-D concerns child support enforcement, and the Title IV-D agency is a separately defined term, not the expenditures a third party may be liable for.