AAPC-CPB Certified Professional Biller - Set 4 - Part 1

Correct Answer: Whether a request for payment meets the requirements for a Medicare claim

The Medicare contractor, not the SSA, makes initial determinations on claims for benefits under Part A and Part B, including whether a request for payment meets the requirements for a Medicare claim. The SSA decides entitlement. Option a is incorrect because age eligibility is one of the entitlement questions the SSA decides, and appeals on it go to the SSA rather than the contractor. Option b is incorrect because railroad beneficiary status is listed among the entitlement issues, so the SSA handles the initial determination and any appeal. Option c is incorrect because deemed insured status is an entitlement question that falls to the SSA, not to the Medicare contractor handling claims.

Correct Answer: Provider is presumed to have knowledge unless proving otherwise

When proper written notice cannot be shown, the provider or supplier is presumed to have knowledge, and thereby liability, unless it proves it did not know and could not reasonably have been expected to know that Medicare would not pay. Option a is incorrect because this reverses the presumption; absent proper written notice, the contractor presumes the provider did know, and liability follows from that presumption. Option c is incorrect because the guidance places the presumption on the provider, not the beneficiary; beneficiary liability under LOL requires evidence of the beneficiary's knowledge, not missing provider notice. Option d is incorrect because Medicare becomes liable only after the provider makes a convincing showing that it did not know and could not reasonably have been expected to know.

Correct Answer: Every 30 days

The continuing care provision recommends that an appropriate claim be submitted every 30 days (monthly), by the beneficiary, sponsor or provider, when services and supplies are rendered on a continuing basis, excluding DRG-based claims. Option b is incorrect because an annual submission would defeat the purpose of lessening the impact of a retroactive denial, which the monthly continuing-care procedure is meant to address. Option c is incorrect because submission after discharge or transfer applies only to claims under the CHAMPUS DRG-based payment system, which are excluded from the continuing-care rule. Option d is incorrect because a quarterly interval is not what the regulation sets; it calls for submission every 30 days (monthly) for continuing care.

Correct Answer: benefits

Under the eligibility for a health plan transaction, an inquiry seeks eligibility to receive health care, coverage of health care, and benefits associated with the benefit plan for an enrollee. Option a is incorrect because encounter information is reported under the health care claims or equivalent encounter information transaction when no direct claim exists, not requested in an eligibility inquiry. Option c is incorrect because a request to obtain payment belongs to the claims transaction, which flows from provider to health plan for health care already delivered. Option d is incorrect because referral certification and authorization is a separate transaction under its own subpart, so it is not an item an eligibility inquiry seeks.

Correct Answer: All services for one provider within a month

The regulation defines claim as a bill for services, a line item of service, or all services for one beneficiary within a bill. Grouping services by provider over a month is not part of that definition. Option a is incorrect because the regulation lists it first among the meanings of claim, so it is a genuine member of the set, not the odd one out. Option b is incorrect because the regulation names it as the third meaning, grouping a single beneficiary's services on one bill into a claim. Option d is incorrect because this is the second meaning the regulation gives, so a single line on a bill qualifies as a claim.

Correct Answer: Not a proper claim

A proper claim is filed timely and meets all other claims filing requirements specified by the plan, program, or insurer, such as prior notification before treatment. Timely filing alone is not enough when a plan requirement is missed. Option a is incorrect because secondary describes Medicare as the residual payer behind primary plans, so it relates to payment order and not to meeting plan filing requirements. Option b is incorrect because prompt describes payment within 120 days for liability, no-fault and workers' compensation insurance, which is a payment timeframe and not a filing standard. Option c is incorrect because a proper claim must be timely and also meet every other filing requirement of the plan, and the missed prior notification breaks that second condition.

Correct Answer: Direct data entry

HIPAA defines direct data entry as data entered directly, for example through dumb terminals or web browsers, and immediately transmitted into a health plan's computer. The scenario matches that definition exactly. Option a is incorrect because it refers to data elements that control the enveloping or hierarchical structure of a transaction, not to how the data reaches the health plan. Option b is incorrect because it names a semantically meaningful unit of information exchanged between two parties to a transaction, which describes the content exchanged rather than keying it into a plan's system. Option d is incorrect because it is the rule describing when a covered entity must use a particular data element or segment, not a way of submitting data.

Correct Answer: Require them to comply with applicable requirements

Under the requirements for covered entities, a covered entity using a business associate must require that business associate to require any agent or subcontractor to comply with all applicable requirements, so the duty passes down the chain. Option a is incorrect because direct data entry is an exception allowing a provider to skip the standard's format requirements, and it is not a duty placed on subcontractors. Option c is incorrect because the rules contain no step of reporting agents or subcontractors to the Secretary; they instead require the business associate to pass on compliance obligations. Option d is incorrect because a clearinghouse is named only as one kind of business associate a covered entity may use, and nothing requires swapping out subcontractors for one.

Correct Answer: Second payer after the supplemental plan

The TRICARE regulation states that CHAMPUS is second payer to other third-party payers of health insurance, including Medicare supplemental plans. The supplemental policy is therefore billed before TRICARE. Option a is incorrect because the regulation does not give TRICARE priority over Medicare supplemental plans; it places CHAMPUS behind other third-party health insurance, which includes those plans. Option b is incorrect because the tertiary position is described for individuals with current employment-based insurance, where the employer plan pays first and Medicare second, not for supplemental coverage. Option d is incorrect because Medicaid is not a double coverage plan, and in any double coverage situation involving Medicaid, CHAMPUS is the primary payer, so this reverses the rule.

Correct Answer: First MSN or RA stating the decision

For appeals of a specific line item or service, the date of the first MSN or RA that states the coverage and payment decision is the date of the initial determination. Option b is incorrect because adjustments and resubmissions on subsequent MSNs or RAs that do not revise the initial determination do not extend or change its appeal rights. Option c is incorrect because that section only explains why additional services or items were reviewed beyond what the appellant indicated; it is not the notice that states the coverage and payment decision. Option d is incorrect because the date of receipt is a presumption, five days after the date on the determination, and it does not fix the determination date.

Correct Answer: I, II, and IV

The State plan must define a claim, and that definition may vary by type of service. The payment standard applies to clean claims from practitioners in individual or group practice or shared facilities. Timing runs from the date of receipt, not the date of service. Option a is incorrect because it leaves out statement IV, which is also accurate: the payment standard covers clean claims from practitioners in individual or group practice or shared health facilities. Option c is incorrect because it includes statement III, but the payment period is counted from the date of receipt, and the date of service governs only the provider's submission limit. Option d is incorrect because it relies on statement III, which confuses the date of service with the date of receipt, and it drops statement II, which is accurate.

Correct Answer: The beneficiary is not asked to sign

When the ABN is issued for care that is statutorily excluded, it serves as a courtesy forewarning of financial obligation. The beneficiary should not be asked to choose an option box or sign the notice. Option b is incorrect because Medicare guidance states the provider or supplier is not required to adhere to the issuance guidelines when the ABN is used for never-covered care. Option c is incorrect because liability shifting under section 1879 applies to denial reasons that trigger required notice, whereas the voluntary notice serves only as a courtesy forewarning of financial obligation. Option d is incorrect because option box selection belongs to the mandatory ABN, but Medicare guidance says the beneficiary should not be asked to choose one in voluntary use.

Correct Answer: Contractor that processed the claim

Neither the contractor nor CMS is a party at the redetermination or reconsideration levels, so neither has a right to appeal there. The other three are recognized parties when the beneficiary is deceased. Option a is incorrect because a provider or supplier lacking other appeal rights may appeal after the beneficiary dies, provided no other party is available to appeal. Option b is incorrect because an individual whose rights on the claim may be affected by the review, such as one liable for payment, counts as a party. Option d is incorrect because Medicaid State agencies hold party status for dually enrolled beneficiaries when they paid or may be liable and filed a timely redetermination request.

Correct Answer: Social Security Administration

Under a memorandum of understanding with the Secretary, the Social Security Administration makes initial Part A and Part B entitlement determinations and initial determinations on applications for entitlement. Beneficiaries direct entitlement appeals to the SSA. Option a is incorrect because the Appeals Council reviews cases after an ALJ decision, a later appeal level rather than the body that makes initial entitlement decisions. Option c is incorrect because an ALJ holds hearings after reconsideration of a decision and does not issue the first entitlement determination. Option d is incorrect because the Medicare contractor makes initial determinations on claims for benefits under Part A and Part B, which is separate from entitlement decisions.

Correct Answer: The MAC with jurisdiction

Among the MAC responsibilities for reconsiderations, the guidance lists preparing and forwarding case files upon request from a QIC. The QIC requests the file from the MAC with jurisdiction using the Redetermination Case File Request Form. Option a is incorrect because the guidance describes AdQIC only as an entity with which MACs enter joint operating agreements, not as the one that prepares and forwards the case file. Option b is incorrect because OMHA Central Operations is where an ALJ hearing request is filed, which is the third level, so it belongs to a later stage than reconsideration. Option d is incorrect because the Appeals Council provides the final level of administrative review, a later step beyond reconsideration, rather than the contractor duty of forwarding files to the QIC.

Correct Answer: Reconsideration request filed with the MAC

A reconsideration request is filed with the QIC, not the MAC. The MAC handles redetermination, and its reconsideration role is limited to supporting tasks such as forwarding case files and effectuating QIC decisions. Option a is incorrect because the Medicare manual chart assigns the first level, redetermination, to the MAC for Part A, Part B and DME claims alike, so this pairing is accurate. Option b is incorrect because the chart lists the Appeals Council itself as the place to file at that level, so this pairing correctly matches level and location. Option c is incorrect because the chart names HHS OMHA Central Operations as the filing location for ALJ hearings, so this pairing is accurate and not the exception.

Correct Answer: Dismiss the request

Under the Medicare manual's rule on failure to file timely, a contractor that does not find good cause for a late redetermination request should dismiss it. Good cause is resolved first, before any other action. Option a is incorrect because the manual provides no such conversion; a late redetermination request without good cause is dismissed rather than moved to the next appeal level. Option c is incorrect because duplicate handling applies when an appellant resubmits a request with a corrected appointment of representative form, not to a request that missed the deadline. Option d is incorrect because the guidance gives the contractor no step of referring a late request back to the beneficiary; the contractor itself acts by dismissing it.

Correct Answer: Dismissal

A dismissal is the action an adjudicator takes when an appeal will not be conducted as requested. Reasons include abandonment, withdrawal, an improper party, unmet amount in controversy, or the appellant's death. Option b is incorrect because a reopening concerns a decision that is revised afterward, producing a revised determination, rather than a refusal to conduct the appeal as requested. Option c is incorrect because a remand sends a case back to the contractor for a new redetermination after a QIC finds an incorrect dismissal; it does not end the request. Option d is incorrect because de novo describes the new, independent evaluation adjudicators perform at each appeal level, which means the appeal is actually being conducted.

Correct Answer: An adjusted MSN or RA

For fully favorable redeterminations, the contractor mails or otherwise transmits an MSN or RA reflecting the adjustment action to each party, or the authorized representative, on the next scheduled release. Option a is incorrect because the portal is only an optional means of transmitting decisions when approved by CMS; it is a delivery channel, not the notice reflecting the adjustment. Option b is incorrect because documentation requests are part of developing the case file before the decision, so they are not sent to communicate an adjustment after the outcome. Option c is incorrect because a dismissal notice is mailed for withdrawals and dismissals, which end the request without a decision, so it does not reflect an adjustment on a favorable decision.

Correct Answer: Interpreting the law differently than CMS

The redetermination reviewer is bound by all applicable statutory and regulatory provisions. The reviewer may not overrule the law or interpret it differently than CMS, nor comment on the legality of any provision. Option a is incorrect because the guidance allows review of the whole claim when appropriate, with an explanation of why other items were reviewed placed in the rationale of the letter. Option b is incorrect because the reviewer should check for sufficient documentation and evidence that services were furnished as billed, even though a finding of fraud is not permitted. Option d is incorrect because when provider documentation from a prior review is missing from the case file, the reviewer is directed to request it from the RACs, UPICs, or SMRC.