CPB – Practice Exam B, Certification Course, Comprehensive Study Guide and
Practice Questions Review
What is the term for the total amount of covered medical expenses a policyholder must pay
each year out-of-pocket before the health insurance company begins to pay any benefits?
A. Copayment
B. Deductible
C. Secondary Payment
D. Coinsurance - ANS ✔✔A deductible is the amount a policyholder pays for health care services
before the health insurance begins to pay.
Which type of insurance covers physicians and other healthcare professionals for liability as to
claims arising from patient treatment?
A. Business liability
B. Bonding
C. Medical malpractice
D. Workers' compensation - ANS ✔✔Medical malpractice insurance is a type of liability
insurance that covers physicians and other healthcare professionals for liability as to claims
arising from patient treatment.
Which of the following does NOT fall under group policy insurance? I. The premium is paid for
by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The
employer selects the plan(s) to offer to employees. IV. Physical exams and medical history
questionnaires are a mandatory part of the application process. V. V. Employee can make
changes to the policy. VI. The employee's spouse and children are not eligible for coverage.
A. III, IV, V
B. II - VI
C. II, IV, V
,D. I, IV, V, VI - ANS ✔✔Group health insurance coverage is a type of health policy that is
purchased by an employer and is offered to eligible employees of the company, and to eligible
dependents of employees. With group health insurance, the employer selects the plan (or
plans) to offer to employees. With an individual policy, you are the only one who can make
changes to your policy and you are the only one who can cancel the coverage. You have full
control over your own policy. Applicants for individual health insurance will need to complete a
medical history questionnaire and have a physical exam when applying for coverage.
Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan.He received
$25,000 from the health plan to provide services for the 175 enrollees on the health plan. The
services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what
must be done?
A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan.
B. Dr. Wallace experienced a loss under the capitated plan and will need to pay $2,000 to the
health plan.
C. Dr. Wallace will need to payout the $2,000 to the 175 enrollees.
D. Dr. Wallace is required to put the $2,000 in a mutual fund. - ANS ✔✔A capitated plan is
where a provider accepts a pre-established payment for providing healthcare services to
enrollees in a health insurance plan. It is a fixed, pre-arranged monthly payment received by a
physician, clinic, or hospital per patient enrolled in a health plan with a capitated contract.
Monthly payment is calculated one year in advance and remains fixed for that year, regardless
of how often the patient needs services. If the provided services cost less than the capitation
amount, there is profit the provider can keep. If the services by the provider to enrollees cost
more than the capitation amount the physician loses money.
What is the deadline for filing a Medicare claim?
A. One year from the date of service
B. 30 days from the date of service
C. 90 days from the date of service
D. Two years from the date of service - ANS ✔✔Medicare claims must be filed no later than 12
months (or 1 full calendar year) after the date when the services were provided. If a claim isn't
, filed within this time limit, Medicare can't pay its share. For example, if you see your doctor on
February 1, 2017 the Medicare claim for that visit must be filed no later than February, 1, 2018.
A provider sees a patient who has TRICARE Standard. The provider is not contracted with
TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The
provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can
the provider bill the patient for?
A. $0.00
B. $20.00
C. $60.00
D. $160.00 - ANS ✔✔TRICARE non-network providers must be certified by the regional TRICARE
MCSC but is not required to accept the TRICARE allowable charge. Because TRICARE paid $140,
the difference between the charge and the payment can be billed to the patient. Non-network
providers can choose to participate on a claim-by-claim basis.
What organization is responsible in evaluating the medical necessity, appropriateness, and
efficiency of the use of healthcare services and procedures?
A. Utilization Review Organization
B. External Quality Review Organization
C. Quality Assurance Organization
D. Managed Care Organization - ANS ✔✔A Utilization Review Organization (URO) is an entity
that has established one or more utilization review programs, to monitor and evaluate the
medical necessity, appropriateness, and efficiency of the use of health care services and
procedures.
Medicaid providers are forbidden by law to:
A. Refer patients to specialists
B. Bill patients for non-covered services
C. Balance bill patients
Practice Questions Review
What is the term for the total amount of covered medical expenses a policyholder must pay
each year out-of-pocket before the health insurance company begins to pay any benefits?
A. Copayment
B. Deductible
C. Secondary Payment
D. Coinsurance - ANS ✔✔A deductible is the amount a policyholder pays for health care services
before the health insurance begins to pay.
Which type of insurance covers physicians and other healthcare professionals for liability as to
claims arising from patient treatment?
A. Business liability
B. Bonding
C. Medical malpractice
D. Workers' compensation - ANS ✔✔Medical malpractice insurance is a type of liability
insurance that covers physicians and other healthcare professionals for liability as to claims
arising from patient treatment.
Which of the following does NOT fall under group policy insurance? I. The premium is paid for
by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The
employer selects the plan(s) to offer to employees. IV. Physical exams and medical history
questionnaires are a mandatory part of the application process. V. V. Employee can make
changes to the policy. VI. The employee's spouse and children are not eligible for coverage.
A. III, IV, V
B. II - VI
C. II, IV, V
,D. I, IV, V, VI - ANS ✔✔Group health insurance coverage is a type of health policy that is
purchased by an employer and is offered to eligible employees of the company, and to eligible
dependents of employees. With group health insurance, the employer selects the plan (or
plans) to offer to employees. With an individual policy, you are the only one who can make
changes to your policy and you are the only one who can cancel the coverage. You have full
control over your own policy. Applicants for individual health insurance will need to complete a
medical history questionnaire and have a physical exam when applying for coverage.
Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan.He received
$25,000 from the health plan to provide services for the 175 enrollees on the health plan. The
services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what
must be done?
A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan.
B. Dr. Wallace experienced a loss under the capitated plan and will need to pay $2,000 to the
health plan.
C. Dr. Wallace will need to payout the $2,000 to the 175 enrollees.
D. Dr. Wallace is required to put the $2,000 in a mutual fund. - ANS ✔✔A capitated plan is
where a provider accepts a pre-established payment for providing healthcare services to
enrollees in a health insurance plan. It is a fixed, pre-arranged monthly payment received by a
physician, clinic, or hospital per patient enrolled in a health plan with a capitated contract.
Monthly payment is calculated one year in advance and remains fixed for that year, regardless
of how often the patient needs services. If the provided services cost less than the capitation
amount, there is profit the provider can keep. If the services by the provider to enrollees cost
more than the capitation amount the physician loses money.
What is the deadline for filing a Medicare claim?
A. One year from the date of service
B. 30 days from the date of service
C. 90 days from the date of service
D. Two years from the date of service - ANS ✔✔Medicare claims must be filed no later than 12
months (or 1 full calendar year) after the date when the services were provided. If a claim isn't
, filed within this time limit, Medicare can't pay its share. For example, if you see your doctor on
February 1, 2017 the Medicare claim for that visit must be filed no later than February, 1, 2018.
A provider sees a patient who has TRICARE Standard. The provider is not contracted with
TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The
provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can
the provider bill the patient for?
A. $0.00
B. $20.00
C. $60.00
D. $160.00 - ANS ✔✔TRICARE non-network providers must be certified by the regional TRICARE
MCSC but is not required to accept the TRICARE allowable charge. Because TRICARE paid $140,
the difference between the charge and the payment can be billed to the patient. Non-network
providers can choose to participate on a claim-by-claim basis.
What organization is responsible in evaluating the medical necessity, appropriateness, and
efficiency of the use of healthcare services and procedures?
A. Utilization Review Organization
B. External Quality Review Organization
C. Quality Assurance Organization
D. Managed Care Organization - ANS ✔✔A Utilization Review Organization (URO) is an entity
that has established one or more utilization review programs, to monitor and evaluate the
medical necessity, appropriateness, and efficiency of the use of health care services and
procedures.
Medicaid providers are forbidden by law to:
A. Refer patients to specialists
B. Bill patients for non-covered services
C. Balance bill patients
