AAPC-CPB Certified Professional Biller - Set 5 - Part 2

Correct Answer: Obtain the expert's consent to public disclosure

The Medicare manual requires a MAC consulting an expert to inform the expert and obtain consent that the opinion may be used, disclosed publicly, and clearly identified as such within the proposed or final LCD. Option a is incorrect because the Contracting Officer Representative approval applies to revisions made outside the standard LCD process, not to the use of an expert's opinion. Option b is incorrect because the 45-day posting duty covers the determination, its evidence summary and rationale, and is not a step for obtaining an expert's agreement. Option c is incorrect because informal meetings are educational sessions for interested parties before a request is submitted, and they are not a condition for using an expert opinion.

Correct Answer: Yes, as an aggrieved party, regardless of service receipt

Under section 1869(f) of the Social Security Act, an aggrieved party may challenge an LCD in effect. The definition includes Medicare Advantage enrollees with physician-documented need for a service the LCD would deny, regardless of whether the service was received. Option a is incorrect because the definition of aggrieved party expressly includes individuals enrolled in a Medicare Advantage plan or another Medicare managed care plan, not just fee-for-service enrollees. Option b is incorrect because the regulation covers a beneficiary in need of an item or service that would be denied, whether or not the service has been received. Option d is incorrect because the challenge right belongs to the aggrieved party, a beneficiary or the beneficiary's estate; the treating physician supplies the documentation of need but is not the challenger.

Correct Answer: 60 days

A party to a QIC reconsideration may request an ALJ hearing at the third level of appeal by filing a written request within 60 days after receipt of the notice of the QIC's reconsideration, provided the amount in controversy requirement is met. Option a is incorrect because 5 days is the time a QIC has to issue a final action after receiving an escalation request, not a filing deadline. Option c is incorrect because 180 days is the window for requesting a reconsideration after receiving the redetermination, which is the second level of appeal rather than the third. Option d is incorrect because 30 calendar days is the effectuation deadline for the MAC after it receives the QIC's effectuation notice, not the filing period for an ALJ hearing request.

Correct Answer: Its coercive effect on the beneficiary

The Medicare manual's timeliness standard warns that last-minute notification can be coercive, and a coercive notice is an invalid notice. A notice must give the beneficiary room to decide without undue pressure. Option a is incorrect because the manual says a written notice should be delivered in person whenever possible, so in-person delivery supports a valid notice and does not invalidate one. Option b is incorrect because timing before disrobing or attachment of equipment is exactly what the timeliness standard expects; it describes a properly timed notice, not a defective one. Option d is incorrect because a header identifying the entity that obtained the notice, rather than the one billing, is still considered valid by the Medicare contractor if otherwise properly executed.

Correct Answer: The beneficiary

Under the liability determination steps for disallowed claims under §1879, the beneficiary is assessed first. If both parties are found to have knowledge, the beneficiary is held liable. Option a is incorrect because the contractor is the reviewer who decides who is liable under the LOL provisions; it does not bear the cost of the item or service. Option c is incorrect because Medicare accepts liability only after the beneficiary and the provider or supplier have both been found not liable, which is not the case here. Option d is incorrect because liability falls on the provider or supplier only when the beneficiary is not found liable and the provider or supplier knew or should have known.

Correct Answer: Redetermination

Redetermination is level 1 and is the only level the contractor performs. Under the where-to-file chart, requests for redetermination are filed with the MAC for Part A, Part B and DME claims. Option b is incorrect because requests at this second level are filed with the QIC, and the contractor only prepares and forwards the case file to it. Option c is incorrect because requests for this third level go to HHS OMHA Central Operations, not to the MAC that handled the claim. Option d is incorrect because this fourth level is filed with the Appeals Council, which is separate from the contractor that makes the redetermination.

Correct Answer: Mailed to the beneficiary's home address

Effective ABN delivery calls for in-person delivery if possible, advance timing, a full explanation and the beneficiary's signature. Mailing the notice to the beneficiary's home is not among the listed elements of effective delivery. Option a is incorrect because timing is addressed directly: the notice must come early enough for the beneficiary to weigh all available options before care is delivered. Option c is incorrect because in-person delivery to the beneficiary is a stated element of effective delivery whenever it can be done, so it belongs in the set. Option d is incorrect because the Medicare manual lists the beneficiary's signature as the final element that makes ABN delivery effective, so it is a genuine requirement.

Correct Answer: Issue a new ABN

Under the period of effectiveness rule, an ABN remains effective only while care, health status and coverage guidelines are unchanged. If any of these changes during treatment, the notifier must issue a new ABN. Option a is incorrect because the original ABN stays effective only while care, health status and coverage guidelines remain unchanged, and here the health status has changed. Option b is incorrect because CMS instructions bar retroactive dating of an ABN and do not let it shift liability for care already provided. Option c is incorrect because the one-year option applies to subsequent treatment of repetitive or continuous care when nothing has changed, not when a listed change occurs mid-treatment.

Correct Answer: Naming one specific contracted supplier

The non-contracted supplier is not required to name a specific contracted supplier. The guidance recognizes suppliers may be reluctant to do so and expects only that the beneficiary be directed to 1-800-MEDICARE, on request, to find one. Option b is incorrect because CMS guidance makes this explanation a condition of validity when a non-contracted supplier issues the ABN for a competitive bidding item, so it is required. Option c is incorrect because suppliers must tell the beneficiary that Medicare will pay for the item if it is obtained from a different supplier in the area, which makes this a required step. Option d is incorrect because the guidance states the explanation of why Medicare may not pay must appear on an ABN that is signed by the beneficiary, so signature is a validity element.

Correct Answer: All suppliers who sell or rent medical equipment and supplies

Medicare manual guidance states that all suppliers who sell or rent medical equipment and supplies to beneficiaries are subject to the DMEPOS refund provisions, whether accepting assignment or not, so assigned and unassigned claims are both covered. Option a is incorrect because the refund provisions reach assigned and unassigned claims alike, so they are not confined to participating suppliers or to durable medical equipment alone. Option b is incorrect because the provisions cover every supplier selling or renting these items; the missing ABN only determines that the beneficiary carries no financial responsibility. Option d is incorrect because contract status is not a condition for the refund provisions, which apply to all suppliers whether or not they accept assignment.

Correct Answer: Notice of Medicare Non-coverage (NOMNC)

When all Medicare covered CORF services are going to end, the CORF must issue the NOMNC, which informs the beneficiary of the right to an expedited determination. An ABN follows only if non-covered care continues. Option a is incorrect because a revocation belongs to the hospice benefit, where the beneficiary exercises freedom of choice, and has no role in ending CORF services. Option b is incorrect because an ABN is issued at termination only if the beneficiary wants to keep receiving services Medicare will not cover, not as the required expedited determination notice. Option c is incorrect because public notices are tied to the Refund Requirements waiver for suppliers of medical equipment and supplies, not to ending CORF care.

Correct Answer: Waiver of interest determination

Determinations with respect to a waiver of interest are listed among the actions that are not initial determinations. Because they are not initial determinations, they are not appealable under the Medicare claims appeals chapter. Option a is incorrect because a claim not payable to a beneficiary for the services of a physician who has opted-out appears among the listed initial determinations. Option c is incorrect because when Medicare pursues recovery directly from an applicable plan, the amount and existence of the recovery claim is an initial determination, so it can be appealed. Option d is incorrect because a payment amount determination for a particular item or service on a claim is expressly an initial determination that is appealable.

Correct Answer: Assignor

The glossary defines an assignor as a beneficiary whose provider or supplier has taken assignment of a claim or of an appeal of a claim. The beneficiary transfers the right, and the provider or supplier receives it. Option b is incorrect because this is an individual a party appoints to represent the party in a claim or appeal, not a beneficiary whose claim or appeal rights were assigned. Option c is incorrect because the assignee is the provider or supplier that furnished the items or services and accepted the assignment, so it sits on the opposite side of the transfer. Option d is incorrect because this term designates whichever party, or party's representative, has filed an appeal; it is defined by the act of filing, not by an assignment.

Correct Answer: more lenience

Medicare guidance expects providers, physicians, and suppliers to file on time and says their extension requests warrant careful examination, while a beneficiary request is to be treated with more lenience. Option a is incorrect because this reverses the guidance, since it is provider, physician, and supplier requests that warrant careful examination and should not be routinely granted. Option b is incorrect because Medicare guidance deliberately separates the two groups, so applying the same standard to both ignores the extra consideration given to beneficiaries. Option d is incorrect because the manual calls for more lenience toward beneficiaries but never describes their requests as granted automatically; good cause must still be found under the MAC's guidelines.

Correct Answer: Make a favorable good cause determination and vacate the dismissal

When an explanation arrives within 6 months of the dismissal and supports good cause, the MAC makes a favorable good cause determination, treats the appeal as timely filed, vacates the dismissal and performs the redetermination. Option a is incorrect because a party has 6 months from the dismissal to supply an explanation, so a submission two weeks afterward falls well inside that window. Option b is incorrect because reopening is a discretionary step reserved for cases where good cause is not found, whereas this explanation supports a finding of good cause. Option c is incorrect because the QIC reviews a dismissal only when the party files a separate request within 60 days of receiving the dismissal notice; the MAC handles an explanation.

Correct Answer: Submitting a written statement of revocation to the contractor

The Medicare manual allows the party who made the appointment to revoke it at any time. Revocation requires a written statement of revocation given to the contractor. Option b is incorrect because the guidance lets the appointing party revoke at any time, so the appointment does not have to stay in place until a decision. Option c is incorrect because that waiver is completed by a provider or supplier representative who furnished the items or services, and it does not end an appointment. Option d is incorrect because filing with that entity is a required element of a written appointment request, not a way of revoking an existing one.

Correct Answer: The beneficiary or the beneficiary's legal guardian

When the party appointing a representative is a beneficiary, only the beneficiary or the beneficiary's legal guardian may sign Section I of the appointment of representative form, and the date of signing must be included. Option a is incorrect because a party may not appoint an organization or group, so an organization is not a valid representative and does not sign for the beneficiary. Option b is incorrect because the named individual signs Section II, acceptance of appointment, which is a separate part of the form from the party's appointment. Option d is incorrect because a provider or supplier signs Section I only when it is the party making the appointment, and here the party is the beneficiary.

Correct Answer: Only the appointed representative

When a MAC takes action or issues a redetermination, it sends notice to only the appointed representative. Notice shall not go to the party while an appointed representative is in place, and requests for information follow the same rule. Option a is incorrect because sending copies to both would contradict the rule that the MAC sends notice to only the appointed representative, not to the party as well. Option b is incorrect because the manual names the appointed representative as the sole recipient and gives no separate notice role to the furnishing provider in this situation. Option c is incorrect because the manual directs notice away from the party whenever an appointed representative exists, stating that notice shall not be sent to the party.

Correct Answer: I and II

A redetermination reviewer may not find criminal or civil fraud, though the claim is checked for evidence that services were furnished as billed. In overpayment appeals, the contractor also reviews who is responsible for the overpayment. Option b is incorrect because it includes statement III, yet a reviewer cannot make a criminal or civil fraud finding; the reviewer only checks whether services were furnished as billed. Option c is incorrect because it pairs valid statement II with IV, but when reconsideration is later requested, the entire case is sent, not just a letter. Option d is incorrect because both statements fail: fraud findings fall outside the reviewer's role in a redetermination, and the whole case moves forward on a reconsideration request.

Correct Answer: Each physician is paid the full global allowed amount for the services furnished.

Medicare limits the combined approved amount for all physicians to what a single physician would have received for the whole package, apart from stated exceptions. Each physician is therefore not paid the full global amount. Option a is incorrect because it accurately states the rule that postoperative, post-discharge care payment is divided between two or more physicians who have agreed on a transfer of care. Option c is incorrect because this matches the manual, which says services of another physician may be paid separately or denied for medical necessity depending on the circumstances when no transfer occurs. Option d is incorrect because the Medicare manual does allow the agreement to take the form of a letter or an annotation in the discharge summary, hospital record, or ASC record.