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

Correct Answer: Physician accepting assignment from the beneficiary

Payment on an assignment-related basis includes Part B payment to a physician or other supplier that accepts assignment from the beneficiary. Payment after the beneficiary's death and payment through a health benefit plan entity are the other listed situations. Option a is incorrect because a Medigap insurer is a private company paying charges Medicare does not pay; it is not a party listed in the assignment-related definition. Option b is incorrect because this entity contracts with CMS to perform program integrity activities and is not a payee under the assignment-related definition. Option d is incorrect because a nonparticipating supplier billing a non-assigned claim receives payment from the beneficiary instead of direct Medicare payment, which falls outside assignment-related payment.

Correct Answer: Debt collector's address

Regulation F bars any language or symbol on an envelope other than the debt collector's address. A business name is allowed only if it does not indicate that the debt collector is in the debt collection business. Option a is incorrect because an account number is a language or symbol other than the address, which the envelope restriction does not permit. Option c is incorrect because the rule allows no language or symbol beyond the address and a permitted business name, so a debt reference is excluded. Option d is incorrect because language indicating the sender is in the debt collection business is barred, even when the business name itself appears on the envelope.

Correct Answer: Actual notice

Regulation F requires a debt collector who sends required disclosures in writing or electronically to do so in a manner reasonably expected to provide actual notice. Relevant factors include the subject line, undeliverability notices and sender identification. Option a is incorrect because is not the standard the commentary names; the delivery manner must be reasonably expected to give actual notice to the consumer. Option b is incorrect because is something a collector obtains and mails after a written dispute, not the result a delivery method is expected to achieve. Option d is incorrect because is not what delivery of required disclosures is measured against; the commentary speaks of expected notice, not any consent from the consumer.

Correct Answer: Overshadowing of rights to dispute

During the validation period, a debt collector must not engage in collection activities or communications that overshadow or are inconsistent with the disclosure of the consumer's rights to dispute the debt and request original-creditor information. Option a is incorrect because a duplicative dispute is a defined term for a repeated written dispute lacking new and material information; it describes a consumer submission, not collector conduct. Option b is incorrect because that duty begins once the consumer disputes in writing within the period, and here the problem is a letter that obscures the right itself. Option c is incorrect because the safe harbor protects a collector who uses the model form as described; it is a defense, not a prohibition a collector could violate.

Correct Answer: Make a finding on good cause

When a redetermination request appears late, the MAC resolves whether good cause exists before taking any other action on the appeal. If good cause is found, the MAC documents the reason in the decision letter or case file. Option b is incorrect because the guidance has the MAC itself resolve the timeliness question on a redetermination request, so no referral to the QIC occurs at this step. Option c is incorrect because that form matters only when a representative acts for a non-beneficiary appellant, and it has no bearing on whether late filing is excused. Option d is incorrect because dismissal for cause applies to an improper party or no right to redetermination, and dismissal for late filing comes only after no good cause is found.

Correct Answer: Reckless disregard of the truth or falsity

The False Claims Act defines knowing and knowingly as actual knowledge, deliberate ignorance, or reckless disregard of the truth or falsity of the information, and requires no proof of specific intent to defraud. Option a is incorrect because the statute states that no proof of specific intent to defraud is required, so this is not a necessary element of acting knowingly. Option b is incorrect because the definition concerns knowledge of the information in the claim, not awareness of the law, and it does not require this. Option d is incorrect because the statutory definition lists actual knowledge, deliberate ignorance and reckless disregard; ordinary carelessness is not among those three standards.

Correct Answer: Extended to the next succeeding workday

Under the Medicare regulation on extension of a period ending on a nonworkday, a deadline falling on a Federal nonworkday, such as a Saturday, is extended to the next succeeding workday. Option b is incorrect because the regulation expressly provides relief when the last day is a Saturday, Sunday or legal holiday, so the deadline does not stay fixed. Option c is incorrect because the regulation moves a deadline falling on a Federal nonworkday forward, not backward, so no earlier filing date is created. Option d is incorrect because that six-month extension is tied to specific events, such as retroactive entitlement notice or recovery of a payment, not to a weekend deadline.

Correct Answer: Business associate

The applicability rule covers health plans, health care clearinghouses, and certain health care providers outright. Business associates are covered separately, and the standards apply to them where provided. Option a is incorrect because a health care provider is covered when it transmits any health information in electronic form in connection with a covered transaction, which is a different condition. Option b is incorrect because the applicability rule lists the health care clearinghouse as a covered entity in its own right, so no where-provided condition is attached to it. Option d is incorrect because a health plan is named directly in the list of entities covered by the standards, requirements, and implementation specifications, without a where-provided limitation.

Correct Answer: Claim denial rate

OIG compliance guidance says a physician practice can improve documentation quality by comparing its claim denial rate to the rates of other practices in the same specialty, to the extent the carrier provides that information. Option a is incorrect because is a requirement an appellant must meet in the appeals process, and failing it can lead to dismissal, so it does not benchmark documentation quality. Option c is incorrect because refers to a Social Security Act provision that gives financial relief to beneficiaries, providers and suppliers; it is not a peer comparison measure. Option d is incorrect because is the presumed receipt of a determination, five days after the date on it, and is an appeals timing rule, not a benchmark.

Correct Answer: The Medicare limiting charge percentage for nonparticipating practitioners and suppliers

The TRICARE regulation sets the balance billing limit for providers who are not participating providers at the same percentage as the Medicare limiting charge percentage for nonparticipating practitioners and suppliers. Option a is incorrect because the Director can waive the limit case by case when a beneficiary asks, which is an exception to the limit, not its definition. Option b is incorrect because the Medicaid payment-in-full rule applies to Medicaid providers, who accept the agency payment plus cost sharing; it does not set the TRICARE balance billing limit. Option c is incorrect because the global surgery package is a Medicare pricing concept for bundled surgical services, and the TRICARE limit is not tied to it.