AAPC CPB - Chapter 3 Practical Application

Use the CPB Chapter 3 Case 9 PDF to answer questions 15 & 16. Verification of Benefits: Jonathan Rushmore Jonathan has a doctor's appointment with Dr. Bradley to discuss pain in his lower back. He has seen Dr. Bradley for back pain multiple times. Dr. Bradley refers him to a Chiropractor. Based on the verification of benefits, what is his co-pay for an In-Network Chiropractic Manipulation? a. $15.00 b. $25.00 c. $45.00 d. $500.00

a. $15.00 Response Feedback: According to the verification of benefits, Jonathan's co-pay for an in-network chiropractic manipulation is $15.00.

Using CPB Chapter 3_Case 3.pdf from the prior question, answer: Cristian's mom, Yvonne, brings him to the office for an ear infection. The providers are in network for both insurance companies involved. Cristian's parents are married. Cristian is covered by both of their insurance policies. The insurance companies both use the birthday rule for coordination of benefits. What is his copay for this visit? a. $30 b. $25 c. $0 d. $35

a. $30 Response Feedback: For coordination of benefits, many insurance carriers utilize the birthday rule. The birthday rule states that the person whose birthday falls earlier in the year, Cristian's father's birthday is May and his mother's is October. NOTE: Keep in mind that since he has two policies, the secondary carrier may pick up the copay so it's important to file a secondary claim and attach the EOB (explanation of benefits) and submit to second policy.

Use this insurance card to answer questions 13 & 14. Joe sees his doctor regularly for diabetes management. His blood glucose level is a little higher than usual, so he goes to the Urgent Care Center for help in decreasing his blood glucose level. What is Joe's co-pay for the urgent care visit? a. $50.00 b. $75.00 c. $100.00 d. $500.00

a. $50.00 Response Feedback: According to Joe's insurance card, he is responsible for a $50 co-pay when he goes to an urgent care center.

Use Case 9 from the prior question to answer this question. Once the claim is processed, the entire claim amount is applied to the deductible. What is the deductible? a. The deductible is what is to be paid by the patient before the insurance company will start to reimburse services. b. The deductible is the fee paid for the office visit. c. The deductible is the fee paid when admitted in the office. d. The deductible can be paid at intervals depending on the goal.

a. The deductible is what is to be paid by the patient before the insurance company will start to reimburse services. Response Feedback: The patient pays 100% of the deductible amount. Once that has been met, cost of the visit/service is shared between the health plan, co-pays, coinsurance.

Use CPB Chapter 3_Case 2.pdf from the prior question, answer: What is the primary ID for the patient? a. 6578358-01 b. 6578358-02 c. 8463579561 d. 159753468

b. 6578358-02 Response Feedback: Jessica's insurance is primary based on the birthday rule. The policy number on Jessica's card is 6578358. Jessica is 6578358-01 and Caroline is 6578358-02.

Use the CPB Chapter 3_Case 3.pdf answer questions 5 & 6. Cristian's mom, Yvonne, brings him to the office for his yearly physical. The providers are in network for both insurance companies involved. Cristian's parents are married. Cristian is covered by both of their insurance policies. What is his copay for this visit? a. $30 b. $25 c. $0 d. $35

c. $0 Response Feedback: It's important to perform insurance verification as some carriers do not charge copays for preventive services.

Use Case 10 from the prior question to answer this question: Jonathan receives chiropractic services for his back pain. After receiving five chiropractic treatments, Dr. Flores refers him to see a specialist. The pain is not improving, and surgery may be needed. What is Jonathan's responsibility when seen by an in-network specialist for the surgery? a. $15.00 b. $30.00 c. $45.00 d. $500.00

c. $45.00 Response Feedback: According to the verification of benefits, Jonathan's co-pay for an in-network specialist surgery is $45.00.

Use this insurance card to answer questions 11 & 12. Mrs. Thompson had a routine mammogram which revealed a small mass in her left breast. Based on the review, Dr. Jacobs orders an additional mammogram. The office must call the insurance carrier to get an authorization for the mammogram. What number should the office call? a. (888) 555-9517 b. (888) 555-6874 c. (888) 555-5643 d. (888) 555-7896

d. (888) 555-7896 Response Feedback: The office is calling for a prior authorization for a mammogram. The number listed on the back of the insurance card for pre-authorizations is 888-555-7896.

Stacy's mom, Angela, brings her to the office for pain in left arm (it appears to be broken). Stacy has insurance with both parents (married - Angela and James). The providers are in network for both insurance companies involved. Using the birthday rule, which insurance carrier is primary and why? a. ABC Health Plan; Angela (mom) brought her to the office making her insurance primary for this visit. b. Concourse Health Plan: Angela's (mom) birthday occurs within the same year as James (dad) birthday. c. Concourse Health Plan; James' (dad) insurance was in effect prior to Angela's (mom) insurance. d. Concourse Health Plan; James' (dad) date of birth month and day is before Angela's (mom).

d. Concourse Health Plan; James' (dad) date of birth month and day is before Angela's (mom). Response Feedback: For coordination of benefits, many insurance carriers utilize the birthday rule. The birthday rule states that the person whose birthday falls earlier in the year, insurance will be primary. Concourse Health Plan is primary because dad's birthday falls earlier in the year.

Using CPB Chapter 3_Case 1.pdf from the prior question, answer: According to this insurance card, is Susan's husband, Eric Smith, covered by her insurance plan? a. Yes; Eric Smith is covered by her insurance plan. b. Yes; Susan Smith has full coverage for her entire family. c. No; Susan Smith is the only person covered by her plan. d. No; Susan Smith and her children are the only members of her family covered by her plan.

d. No; Susan Smith and her children are the only members of her family covered by her plan. Response Feedback: The bottom of Susan Smith's insurance card shows coverage includes Medical EMP/CH. This means she has medical coverage for her and her children.

Use Case 8 from the prior question to answer this question. The office calls ABC Health Plan and is unable to verify coverage based on the patient's demographics given. How should the office proceed? a. Review the patient's demographics and ensure all information is accurate. b. Call the patient to make correction to the patient's demographics and then attempt to verify coverage. c. Tell the patient that she has no coverage. d. Inform the patient of the error as the patient will need to pay for the service out of pocket.

b. Call the patient to make correction to the patient's demographics and then attempt to verify coverage. Response Feedback: The office should contact the patient to obtain the correct demographic information, then attempt to verify coverage again.

Use the CPB Chapter 3_Case 4.pdf answer the following question. How should the demographics for Mr. Dailey be entered into your system and why? a. Robert J Dailey as she entered in her form b. R J Dailey as printed on card c. Robert Dailey the patient's name d. It doesn't matter

b. R J Dailey as printed on card Response Feedback: It's important that the patient name is entered into the system as it is written on the insurance card. Although the patient's name is Robert, he registered his plan under R J Dailey. You may want to make a note in your system that his name is Robert, however for submission of the claim it must match the card.

Use the CPB Chapter 3_Case 2.pdf to answer questions 3 & 4. Caroline's mom, Jessica, brings her to the office for hives. The providers are in network for both insurance companies involved. Caroline's mom and dad are married. Caroline is covered by both of their insurance policies. The insurance companies both use the birthday rule for coordination of benefits. Which insurance carrier is primary and why? a. XYZ Insurance; Jessica (mom) brought her to the office making her insurance primary for this visit. b. XYZ Insurance; Jessica's (mom) birthday occurs earlier in the year than Thomas' (dad) birthday. c. ABC Insurance; Thomas' (dad) insurance was in effect prior to Jessica's (mom) insurance. d. ABC Insurance; Thomas' (dad) year of birth is before Jessica's (mom).

b. XYZ Insurance; Jessica's (mom) birthday occurs earlier in the year than Thomas' (dad) birthday. Response Feedback: For coordination of benefits, many insurance carriers utilize the birthday rule. The birthday rule states that the person whose birthday falls earlier in the year.

On 12/20/20XX, Mr. Smith had an appt with Dr. Taylor to discuss pain in his lower joint. During the visit, Dr. Taylor ordered a pain injection. No additional follow up or testing was done. Why is this encounter form considered incomplete? a. The encounter form does not show any follow up labs or X-Rays to be done. b. The encounter form does not show Mr. Smith's date of birth in the correct format. c. The encounter form is missing the reason for the visit, diagnosis code and physician signature of the order(s). d. The encounter form is complete.

c. The encounter form is missing the reason for the visit, diagnosis code and physician signature of the order(s). Response Feedback: The encounter form must be fully complete, so the claim can be submitted correctly for payment. The encounter form is missing the reason for the visit and a diagnosis code.

Review the card and provide the insurance ID for Joshua. a. H12345678 b. H1234567801 c. H1234567803 d. H1234567805

d. H1234567805 Response Feedback: When entering the patient ID, it's important to review the patient indicator that is listed next to the patient name. In this case we were entering the information for Joshua which is patient # 5 on the card. There is a total of 6 covered under this plan.

Use the CPB Chapter 3_Case 1.pdf to answer questions 1 & 2. 1. Susan smith arrives at her in-network primary care physician's office for her annual preventive visit. What is her copay? a. $15.00 b. $50.00 c. $75.00 d. The patient does not have a copay for preventive visits.

d. The patient does not have a copay for preventive visits. Response Feedback: On the insurance card, under the copay column for In-network, is N/A next to preventive. This indicates the patient does not have a copay for preventive services.