AAPC-CPB Certified Professional Biller - Set 1 - Part 2

Correct Answer: Gatekeeper referral requirement

Under the Medicare Advantage rule on types of plans, coordinated care plans may control utilization through referrals from a gatekeeper, meaning an enrollee obtains services within the plan only through that referral process. Option b is incorrect because CMS approval of the network ensures access and availability, service area, and quality requirements are met; it is a network standard, not a utilization control. Option c is incorrect because a SNP is a specialized MA plan type that meets CMS's SNP requirements; it identifies a kind of plan rather than a way to control utilization. Option d is incorrect because financial arrangements are listed separately in the same provision, offering providers incentives for high quality, cost-effective care, whereas the excerpt describes referrals needed before an enrollee receives services.

Correct Answer: licensed or approved under State law

The multiple plans provision allows an MA organization to offer multiple plans, regardless of type, provided it is licensed or approved under State law to provide those types of plans. A PSO plan may rely on a CMS waiver instead. Option a is incorrect because the regulation names no accreditation requirement for offering multiple plans; the condition it states comes from State law, not private review. Option b is incorrect because providers are paid by the plan and do not certify the organization; the regulation ties eligibility to State law licensure or approval instead. Option c is incorrect because enrollees take no part in this condition, which concerns the organization's standing to offer plan types under its contract and State law.

Correct Answer: One or more counties

The definition of service area in the MA regulation states that for local MA plans it is one or more counties, while for MA regional plans it is a region approved by CMS. Option a is incorrect because describes the service area of an MA regional plan, not a local plan, which is defined by counties. Option b is incorrect because is not a unit named in the definition; local plan service areas are built from counties, not whole states. Option d is incorrect because is the feature of a coordinated care plan that delivers the benefit package, not the geographic area where enrollment is allowed.

Correct Answer: National Commission on Quality Assurance

Under the MA regulation on types of plans, all SNPs must submit their model of care to CMS for evaluation and approval by the National Commission on Quality Assurance (NCQA), and MA plans offering a SNP need NCQA approval. Option a is incorrect because a state Medicaid agency is a party to the capitated contract of certain dual eligible SNPs, not the evaluator of the model of care. Option c is incorrect because a provider-sponsored organization is one kind of entity that offers coordinated care plans, so it is a plan sponsor rather than an approving body. Option d is incorrect because a parent organization may hold a Medicaid capitated contract or be treated as part of the MA organization, but it does not approve models of care.

Correct Answer: Step therapy

Step therapy is defined as a utilization management policy for coverage of drugs. It begins medication with the most preferred or cost effective drug therapy and progresses to other drug therapies if medically necessary. Option b is incorrect because this term names an MA eligible individual who is institutionalized, entitled to medical assistance under a State plan, or has a severe or disabling chronic condition, not a drug policy. Option c is incorrect because this term is used in the definition of a special needs individual to describe an enrollee's living situation, and it says nothing about drug therapy sequencing. Option d is incorrect because this is an MA coordinated care plan that exclusively enrolls special needs individuals and provides Part D benefits to all enrollees, so it describes a plan type rather than a coverage policy.

Correct Answer: Medical savings account plan

Under the rule for MA plans' Part D coverage, MA organizations offering MSA plans are not permitted to offer prescription drug coverage other than that required under Parts A and B of Title XVIII. Option a is incorrect because the rule on prescription drug coverage does not single out this plan type; its waiver concerns State licensing, not drug benefits. Option b is incorrect because an MA organization offering this plan type can choose to offer qualified Part D coverage within that plan, so no prohibition applies. Option d is incorrect because this plan type is actually required to carry qualified Part D coverage, either in that plan or in another MA plan in the same area.

Correct Answer: Loss ratio, standardized benefit packages, and consumer protection requirements

The Omnibus Budget Reconciliation Act requires all Medigap policies to conform to minimum standards including loss ratio requirements, standardized benefit packages and consumer protection requirements. These apply to policies meeting the statutory Medigap definition. Option a is incorrect because specified disease and hospital indemnity are limited benefit coverage areas that a Medigap policy typically does not include, and employer plans are excluded from the definition. Option c is incorrect because these are not the minimum standards named by the federal law for Medigap, which lists loss ratio, standardized benefits and consumer protection. Option d is incorrect because these relate to how claims information moves to the Medigap insurer, not to the minimum standards the law imposes on the policies themselves.

Correct Answer: Transfer policy does not apply to nonparticipating physicians

Medigap assignment of claims and transfer policy covers participating physicians, practitioners and suppliers only. It does not apply to nonparticipating physicians/practitioners or suppliers, so no Medicare transfer to the Medigap insurer would result for this practice. Option b is incorrect because for assigned claims, Medicare itself must transfer the claims information to the Medigap insurer, so the beneficiary does not carry out that step. Option c is incorrect because free standard-format information is furnished to Medicaid agencies, while Medigap insurers must pay a CMS established per claim crossover fee for Medicare paid claims data. Option d is incorrect because the manual says transfer of claim information applies regardless of whether the state has an approved Medigap program, so state approval is not the deciding factor.

Correct Answer: Medigap policy

A Medigap policy is offered by a private company to those entitled to Medicare benefits. It pays Medicare charges not payable because of deductibles, coinsurance amounts or other Medicare imposed limitations. Option a is incorrect because the Medigap definition explicitly excludes a policy or plan offered by an employer to employees or former employees. Option c is incorrect because specified disease coverage is another limited benefit area, and it pays for named conditions rather than Medicare deductibles and coinsurance. Option d is incorrect because hospital indemnity is a limited benefit coverage area that a Medigap policy typically does not include, so it does not describe this policy.

Correct Answer: Working Aged

Working Aged is the MSP term for Medicare beneficiaries age 65 or older who have GHP coverage through their own or a spouse's current employment status. For this group, Medicare is secondary. Option a is incorrect because it means forgiveness of a party's obligation to satisfy Medicare's claim, in whole or in part, when conditions are met. Option b is incorrect because it is a Medicare payment made on condition of reimbursement when another insurer is primary, not a category of employed beneficiary. Option c is incorrect because it refers to the 30 months in which Medicare is secondary to a GHP for individuals eligible because of ESRD.

Correct Answer: Medicare is secondary to the large group health plan

Medicare is secondary to a large group health plan for individuals under age 65 entitled on the basis of disability when coverage rests on their own or a family member's current employment with a qualifying employer. Option a is incorrect because primacy follows the MSP rules rather than an agreement, and the guidance gives no option for the plan to shift payment order by contract. Option c is incorrect because a plan provision stating its benefits are secondary to Medicare does not change the result; Medicare remains secondary for these beneficiaries despite such wording. Option d is incorrect because disability entitlement does not make Medicare primary here; the guidance makes Medicare secondary when large group health plan coverage rests on current employment status of the individual or a family member.

Correct Answer: secondary

During the ESRD coordination period the group health plan is billed first. If it does not pay covered services in full, Medicare may pay secondary benefits that supplement the plan's payment. Option b is incorrect because Medicare would pay primary benefits only where the plan denies a service as not a plan benefit, which is not a supplement to a partial payment. Option c is incorrect because prospective describes the timing of a request to exempt an employer, not a category of Medicare benefit paid after a plan. Option d is incorrect because conditional payment is a different concept: Medicare pays it when another insurer is primary but slow to pay, and it is repaid once that payer pays.

Correct Answer: Lump Sum Commutation Settlement

A Lump Sum Commutation Settlement is a workers' compensation settlement in which the beneficiary accepts one lump sum that compensates for all future medical expenses and disability benefits related to the work injury or disease. Option a is incorrect because it provides less total compensation than full reimbursement for lost wages and lifelong medical treatment, and it may occur when compensability is contested. Option b is incorrect because a liability insurer or other entity carrying liability insurance makes it, so it is not a workers' compensation settlement type. Option d is incorrect because parties set aside funds under it for future medical and prescription drug services; it is a protective arrangement and not a settlement type.

Correct Answer: Uninsured motorist insurance

Uninsured motorist insurance has the policyholder's insurer pay for damages caused by a motorist who has no automobile liability insurance or carries less than the amount of insurance required by law, which matches this collision. Option a is incorrect because it extends the policyholder's own protection to make up for inadequate coverage in the policyholder's own policy or plan, not for damages caused by another motorist's shortfall. Option b is incorrect because it is an administrative mechanism allocating part of a settlement, judgment or award for future medical or prescription drug expenses, not a coverage type paying damages. Option c is incorrect because it describes an individual or entity carrying its own risk instead of buying insurance from a carrier, which is not the policyholder's insurer paying for another's damage.

Correct Answer: The voluntary prescription drug benefit program

The Medicare definitions state that Medicare Part D means the voluntary prescription drug benefit program authorized under Part D of title XVIII of the Act. Enrollment in the drug benefit is optional. Option a is incorrect because that description belongs to Medicare Part A, which the regulations define by hospital insurance benefits rather than by drug coverage. Option c is incorrect because this is how the regulations define Medicare Part C, which offers plan choices instead of a stand-alone prescription drug benefit. Option d is incorrect because the regulations assign this wording to Medicare Part B, a separate program authorized under its own part of title XVIII.

Correct Answer: Conditional payment

A conditional payment is a Medicare payment, conditioned upon reimbursement to Medicare, for items or services for which another insurer is the primary payer. Medicare expects repayment if the primary insurer later pays. Option a is incorrect because this names the 30-month span in which Medicare benefits are secondary to GHP benefits for ESRD-eligible individuals, not a payment type. Option b is incorrect because a compromise is a settlement in which the Regional Office or Central Office accepts less than the full debt owed to Medicare. Option c is incorrect because this is the amount determined to be owed to Medicare in workers' compensation, no-fault, and liability matters, not the original payment itself.

Correct Answer: Proper claim

A proper claim is defined in the Medicare manual as a claim filed timely that meets all other claims filing requirements specified by the plan, program, or insurer, such as mandatory second opinion or prior notification. Option a is incorrect because this term means the amount determined to be owed to the Medicare program in WC, no-fault and liability matters, not a claim filed with a plan. Option c is incorrect because prompt describes payment within 120 days for liability, no-fault and WC insurance, so it addresses payment timing rather than the filing requirements a claim must meet. Option d is incorrect because conditional describes Medicare payments made on condition of reimbursement if the primary plan later pays, and is not a defined claim-filing standard.

Correct Answer: A proper claim was filed and the plan denied it in part

Conditional primary Medicare benefits may be paid when the beneficiary, provider, or supplier that accepted assignment filed a proper claim under the GHP and the plan denied it in whole or in part, provided the exclusions do not apply. Option a is incorrect because failure to file a proper claim, including timely filing, bars conditional payment unless physical or mental incapacity caused it, and no incapacity exists in this option. Option b is incorrect because this allegation is one of the listed denial reasons for which conditional primary payments may not be made, so it blocks payment rather than supporting it. Option d is incorrect because a plan restricting payment because the individual is entitled to Medicare appears among the denial reasons that prevent conditional primary payment, not among the permitted circumstances.

Correct Answer: payment in full

Under the regulation on acceptance of State payment, a State plan must limit participation to providers who accept the agency payment plus any required deductible, coinsurance or copayment as payment in full. Option a is incorrect because the provision does not describe negotiation; it requires acceptance of the agency amount and plan-required cost sharing as the full payment. Option c is incorrect because the regulation treats the agency payment plus required cost sharing as complete payment, not as an advance that leaves a balance to collect. Option d is incorrect because the rule attaches no conditions to the agency payment; the provider accepts it together with required cost sharing as the complete amount.

Correct Answer: Legal authorization by the State to deliver services

Under the Medicaid definitions, a managed care provider is engaged in delivering health care and is legally authorized by the State to do so. A fee-for-service provider is defined by an agreement with the Medicaid agency. Option b is incorrect because this is the test used for the fee-for-service program, where a provider furnishes services under an agreement with the Medicaid agency. Option c is incorrect because PCCM is only a defined abbreviation for primary care case manager, a role that is not what makes someone a provider in either delivery system. Option d is incorrect because FFP is the Federal Government's share of State Medicaid expenditures, a funding concept that has no bearing on who qualifies as a provider.