AAPC-CPB Certified Professional Biller - Set 1 - Part 3

Correct Answer: Title IV-D agency

The regulations define the Title IV-D agency as the State organizational unit responsible for administering or supervising administration of a State plan for child support enforcement under title IV-D of the Act. Option a is incorrect because the regulations place it in cooperative agreements with other entities to obtain third party payments, a different role from administering child support enforcement. Option b is incorrect because it covers commercial insurance companies, prepaid plans and organizations administering health or casualty plans, which are payers and not a State unit handling child support enforcement. Option d is incorrect because it is the broad term for any individual, entity or program that may be liable to pay medical assistance expenditures, not a particular State unit.

Correct Answer: A/B MAC (A) and (HHH)

The A/B MAC (A) and (HHH) is a public or private agency or organization with an agreement with CMS to enroll legitimate providers, including HHAs, and process Medicare Part A and Part B claims. Option a is incorrect because it is one of two major agencies, alongside CMS, involved in specified administrative functions under DHHS; the guidance does not assign it provider enrollment or claims processing. Option b is incorrect because the State agency certifies to DHHS whether facilities meet conditions of participation, which is a certification function and not claims processing under an agreement with CMS. Option c is incorrect because CMS consults with it when determining an individual's entitlement to benefits, so its role concerns beneficiary entitlement and not institutional provider enrollment or claims.

Correct Answer: She is exempt from cooperating in obtaining support from the non-custodial parent

Under the State plan requirements for assignment of rights, pregnant women are exempt from cooperating in establishing a child's parentage and obtaining medical support or payments from the non-custodial parent. Her agreement to assign third party rights satisfies the separate assignment requirement. Option a is incorrect because the regulation treats assignment and cooperation as separate requirements, and pregnant women are specifically exempt from the paternity and support cooperation requirement. Option b is incorrect because good cause relates to excusing a failure to cooperate, not to accepting an assignment, and she has already agreed to assign her rights. Option d is incorrect because the pregnant-women exemption covers only the parent identity and non-custodial parent support requirement, while cooperation in pursuing other liable third parties still applies unless good cause is shown.

Correct Answer: The Medicaid agency receives the data in standard format at no charge.

The Medicare manual states that Medicaid agencies are furnished Medicare claims information in the standard format free of charge. Other commercial payers, including Medigap insurers, are the ones that pay a CMS established per claim crossover fee. Option a is incorrect because reimbursement of CMS's designated COBA contractor is a duty of the Medigap insurer, not of a Medicaid agency, which pays nothing. Option c is incorrect because that per claim crossover fee is charged to other commercial payers, including Medigap insurers, while Medicaid agencies are furnished the information in the standard format free of charge. Option d is incorrect because assignment of claims and the resulting transfer of claim information describe the Medigap process, which is separate from the free standard-format information furnished to Medicaid agencies.

Correct Answer: The patient is a beneficiary based on Medicare entitlement alone.

The definition of beneficiary in the regulations uses "and/or", so entitlement to Medicare benefits is enough by itself. A Medicaid eligibility determination is an alternative basis, not an added requirement. Option a is incorrect because the definition joins the two bases with "and/or", so a Medicaid determination is not a required second step for Medicare-entitled persons. Option b is incorrect because the 90-day facility residence requirement belongs to the definition of institutionalized for special needs plans, not to the general beneficiary definition. Option c is incorrect because the definition names persons entitled to Medicare benefits as one group within the term, so Medicare entitlement is not left out.

Correct Answer: Department of Defense, through DEERS

The Department of Defense, through the Defense Enrollment Eligibility Reporting System (DEERS), is responsible for establishing and maintaining the listing of persons eligible for CHAMPUS benefits. CHAMPUS relies primarily on DEERS for eligibility verification. Option b is incorrect because the Director negotiates contracts, monitors claims processing and develops policies, but the eligibility listing is assigned to the Department of Defense through DEERS. Option c is incorrect because the Uniformed Services issue identification cards bearing preliminary evidence of eligibility, which remains subject to verification through DEERS, so they do not maintain the listing. Option d is incorrect because fiscal intermediaries receive and adjudicate CHAMPUS claims under their contracts, and the regulation does not assign them the eligibility listing.

Correct Answer: Take action to be reinstated and obtain a new identification card

When Medicare eligibility ceases for end-stage renal disease patients, CHAMPUS eligibility resumes if the person is otherwise still eligible. The person must take action to be reinstated as a CHAMPUS beneficiary and obtain a new identification card. Option a is incorrect because the Health Benefits Advisor only assists and advises, has no authority to make benefit determinations, and does not reinstate eligibility. Option b is incorrect because the regulation places the burden on the person, who must act to be reinstated and obtain a new card, so passive waiting does not restore coverage. Option c is incorrect because a retiree who waives retired pay is still considered a retiree for CHAMPUS eligibility, so a waiver changes nothing about reinstatement.

Correct Answer: Director, OCHAMPUS

Under the program integrity provision, the Director, OCHAMPUS, or a designee, oversees CHAMPUS personnel, fiscal intermediaries, providers, and beneficiaries, using delegation of authority, reports, performance evaluations, and management and fiscal audits to ensure compliance. Option b is incorrect because this commander generally appoints the advisor, but the regulation gives program integrity oversight of personnel, intermediaries, providers, and beneficiaries to a different official. Option c is incorrect because the advisor only assists beneficiaries and staff with applications and claims, is not responsible for CHAMPUS policies and procedures, and has no authority over compliance programs. Option d is incorrect because a fiscal intermediary is itself among the parties overseen, and its claims adjudication contracts are monitored by OCHAMPUS rather than directing program integrity.

Correct Answer: Contemporaneous clinical records

TRICARE-authorized providers must maintain contemporaneous clinical records that substantiate the clinical rationale for each course of treatment, periodic evaluation of the efficacy of treatment, and the outcome at completion or discontinuation of treatment. Option a is incorrect because is a signed agreement some hospitals not participating in Medicare must submit to be approved; it does not document treatment rationale or outcome. Option b is incorrect because describes an operational plan an acute care hospital must have in effect, not a record documenting the rationale and outcome of each course of treatment. Option d is incorrect because must be obtained before rendering designated services whose cost-share may be expected, so it addresses preauthorization rather than documenting treatment rationale, evaluation and outcome.

Correct Answer: I and II

A Nonavailability Statement is issued when the Uniformed Services facility cannot provide the required care. When required, except for emergencies, it must be issued before care is obtained from civilian sources. Statements I and II match this rule. Option b is incorrect because statement III describes the deductible certificate, a separate document obtained from the fiscal intermediary where the deductible was met, not the Nonavailability Statement. Option c is incorrect because statement IV contradicts the timing rule, since a required statement must exist before civilian care is obtained, and this choice also drops statement I. Option d is incorrect because it adds the deductible certificate's purpose as statement III and a post-care issuance in statement IV, which the before-care rule rules out.