|ACTUAL EXAM
QUESTIONS WITH WELL DETAILED CORRECT ANSWERS|GRADED
A+|BRAND NEW 2026/2027 UPDATE
Which type of managed care insurance allows patients to self-refer to out-of-network
providers and pay a higher co-insurance/copay amount?
I. HMO
II. PPO
III. EPO
IV. POS
V. Capitation
A. II
B. IV
C. II and IV
D. II, III, and V - ANSWER ANSWER:
C - Point-of-Service Plan (POS) and Preferred Provider Organization (PPO) allow patients the
flexibility to self-refer to a specialist instead of requiring a referral from a primary care
provider. A patient is required to pay a higher deductible, co-insurance, or co-payment
amount when he/she sees an out-of-network provider
A patient covered by a PPO is scheduled for knee replacement surgery. The biller contacts
the insurance carrier to verify benefits and preauthorize the procedure. The carrier verifies
the patient has a $500 deductible which must be met. After the deductible, the PPO will pay
80% of the claim. The contracted rate for the procedure is $2,500. What is the patient's
responsibility?
A. $400
B. $500
1
,C. $900
D. $1,600 - ANSWER ANSWER:
C - The contracted rate is $2500. The patient must pay the deductible ($500) and 20% of
$2,000 ($400). The total patient responsibility is $900.
When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment
processed?
A. The payment is sent to the patient and the patient must pay the provider
B. The payment is sent to the provider if the provider agrees to accept assignment
C. The payment is sent to the provider regardless of if he accepts assignment.
D. The claim is not paid because the provider is not participating in the plan - ANSWER
ANSWER:
A - Even when nonparticipating providers with BC/BS agree to submit the claim for the
patient or accept assignment, BC/BS sends the payment to the patient. The patient is
responsible for paying the provider.
Which of the following TRICARE options is/are available to active-duty service members?
A. TRICARE Select
B. TRICARE Prime
C. TRICARE For Life
D. TRICARE Young Adult - ANSWER ANSWER:
B - All active-duty members must choose TRICARE Prime. TRICARE Select, TRICARE For Life,
and TRICARE Young Adult are for active-duty family members.
2
, A Medicare card will list which of the following:
I. Effective date of coverage
II. Home address
III. Telephone Number
IV. Entitled to Part A and/or Part B
V. When coverage ends
VI. Name of Primary Care Physician
A. I - VI
B. I, IV
C. I-III, VI
D. I, II, IV, V - ANSWER ANSWER:
B - Medicare card lists:
The patient name
Medicare claim number (or Medicare number)
Effective date of coverage
Sex/Gender
Entitled to Medicare Part A and/or B (The card will not show if the patient has Part C or Part
D coverage)
Effective Date
In which of the following scenarios is Medicare the secondary payer?
I. A 65-year-old patient who is collecting her deceased spouse's Medicare benefits and has a
supplemental insurance
II. A 72-year-old patient who participates in the group health insurance of his employer
III. A 66-year-old patient is injured at work and the employer does not offer health insurance
as a benefit of employment
3
QUESTIONS WITH WELL DETAILED CORRECT ANSWERS|GRADED
A+|BRAND NEW 2026/2027 UPDATE
Which type of managed care insurance allows patients to self-refer to out-of-network
providers and pay a higher co-insurance/copay amount?
I. HMO
II. PPO
III. EPO
IV. POS
V. Capitation
A. II
B. IV
C. II and IV
D. II, III, and V - ANSWER ANSWER:
C - Point-of-Service Plan (POS) and Preferred Provider Organization (PPO) allow patients the
flexibility to self-refer to a specialist instead of requiring a referral from a primary care
provider. A patient is required to pay a higher deductible, co-insurance, or co-payment
amount when he/she sees an out-of-network provider
A patient covered by a PPO is scheduled for knee replacement surgery. The biller contacts
the insurance carrier to verify benefits and preauthorize the procedure. The carrier verifies
the patient has a $500 deductible which must be met. After the deductible, the PPO will pay
80% of the claim. The contracted rate for the procedure is $2,500. What is the patient's
responsibility?
A. $400
B. $500
1
,C. $900
D. $1,600 - ANSWER ANSWER:
C - The contracted rate is $2500. The patient must pay the deductible ($500) and 20% of
$2,000 ($400). The total patient responsibility is $900.
When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment
processed?
A. The payment is sent to the patient and the patient must pay the provider
B. The payment is sent to the provider if the provider agrees to accept assignment
C. The payment is sent to the provider regardless of if he accepts assignment.
D. The claim is not paid because the provider is not participating in the plan - ANSWER
ANSWER:
A - Even when nonparticipating providers with BC/BS agree to submit the claim for the
patient or accept assignment, BC/BS sends the payment to the patient. The patient is
responsible for paying the provider.
Which of the following TRICARE options is/are available to active-duty service members?
A. TRICARE Select
B. TRICARE Prime
C. TRICARE For Life
D. TRICARE Young Adult - ANSWER ANSWER:
B - All active-duty members must choose TRICARE Prime. TRICARE Select, TRICARE For Life,
and TRICARE Young Adult are for active-duty family members.
2
, A Medicare card will list which of the following:
I. Effective date of coverage
II. Home address
III. Telephone Number
IV. Entitled to Part A and/or Part B
V. When coverage ends
VI. Name of Primary Care Physician
A. I - VI
B. I, IV
C. I-III, VI
D. I, II, IV, V - ANSWER ANSWER:
B - Medicare card lists:
The patient name
Medicare claim number (or Medicare number)
Effective date of coverage
Sex/Gender
Entitled to Medicare Part A and/or B (The card will not show if the patient has Part C or Part
D coverage)
Effective Date
In which of the following scenarios is Medicare the secondary payer?
I. A 65-year-old patient who is collecting her deceased spouse's Medicare benefits and has a
supplemental insurance
II. A 72-year-old patient who participates in the group health insurance of his employer
III. A 66-year-old patient is injured at work and the employer does not offer health insurance
as a benefit of employment
3
