|ACTUAL EXAM
QUESTIONS WITH WELL DETAILED CORRECT ANSWERS|GRADED
A+|BRAND NEW 2026/2027 UPDATE
Joe and Mary are a married couple and both carry insurance from their employers. Joe was
born on February 23, 1977 and Mary was born on April 4, 1974. Using the birthday rule, who
carries the primary insurance for their children for billing?
A. Joe, because he is the male head of the household.
B. Mary, because her date of birth is the 4th and Joe's date of birth is the 23rd.
C. Mary, because her birth year is before Joe's birth year.
D. Joe, because his birth month and day are before Mary's birth month and day. -
ANSWER D. Joe, because his birth month and day are before Mary's birth month and day.
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 C. II and IV
1
,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
C. $900
D. $1,600 - ANSWER C. $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 if he accepts assignment.
D. The claim is not paid because the provider is not participating in the plan. - ANSWER A.
The payment is sent to the patient and the patient must pay 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 B. TRICARE Prime
A Medicare card will list which of the following:
2
,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 B. I, IV
When a patient has Medicare primary and AARP as Medigap, what is entered on the CMS-
1500 claim form in item 9d for the Insurance Plan Name or Program Name for Medicare to
cross over the claim?
A. Plan name followed by "MEDIGAP"
B. Plan Payer ID followed by "MEDIGAP"
C. COBA Medigap claim-based identifier (ID)
D. Leave blank - ANSWER C. COBA Medigap claim-based identifier (ID)
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
, IV. A 55 year-old patient who is on disability through Social Security and qualifies for
Medicaid and Medicare
A. I-IV
B. II and III
C. I and IV
D. None - ANSWER B. II and III
Which guidelines must all billing personnel be knowledgeable about in order to ensure
compliance with Medicaid programs?
A. Federal guidelines
B. State guidelines
C. Both A and B
D. None - ANSWER C. Both A and B
Which of the following services is covered by Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT)?
A. Family planning
B. Obstetric care
C. Pediatric checkups
D. Emergency department visits - ANSWER C. Pediatric checkups
A female patient who was involved in an auto accident presents to the emergency
department (ED) for evaluation. She does not have any complaints. The provider evaluates
her and determines there are no injuries. The provider informs the patient to come back to
the ED or see her primary care physician if she develops any symptoms. How is the claim
processed for this encounter?
4
QUESTIONS WITH WELL DETAILED CORRECT ANSWERS|GRADED
A+|BRAND NEW 2026/2027 UPDATE
Joe and Mary are a married couple and both carry insurance from their employers. Joe was
born on February 23, 1977 and Mary was born on April 4, 1974. Using the birthday rule, who
carries the primary insurance for their children for billing?
A. Joe, because he is the male head of the household.
B. Mary, because her date of birth is the 4th and Joe's date of birth is the 23rd.
C. Mary, because her birth year is before Joe's birth year.
D. Joe, because his birth month and day are before Mary's birth month and day. -
ANSWER D. Joe, because his birth month and day are before Mary's birth month and day.
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 C. II and IV
1
,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
C. $900
D. $1,600 - ANSWER C. $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 if he accepts assignment.
D. The claim is not paid because the provider is not participating in the plan. - ANSWER A.
The payment is sent to the patient and the patient must pay 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 B. TRICARE Prime
A Medicare card will list which of the following:
2
,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 B. I, IV
When a patient has Medicare primary and AARP as Medigap, what is entered on the CMS-
1500 claim form in item 9d for the Insurance Plan Name or Program Name for Medicare to
cross over the claim?
A. Plan name followed by "MEDIGAP"
B. Plan Payer ID followed by "MEDIGAP"
C. COBA Medigap claim-based identifier (ID)
D. Leave blank - ANSWER C. COBA Medigap claim-based identifier (ID)
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
, IV. A 55 year-old patient who is on disability through Social Security and qualifies for
Medicaid and Medicare
A. I-IV
B. II and III
C. I and IV
D. None - ANSWER B. II and III
Which guidelines must all billing personnel be knowledgeable about in order to ensure
compliance with Medicaid programs?
A. Federal guidelines
B. State guidelines
C. Both A and B
D. None - ANSWER C. Both A and B
Which of the following services is covered by Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT)?
A. Family planning
B. Obstetric care
C. Pediatric checkups
D. Emergency department visits - ANSWER C. Pediatric checkups
A female patient who was involved in an auto accident presents to the emergency
department (ED) for evaluation. She does not have any complaints. The provider evaluates
her and determines there are no injuries. The provider informs the patient to come back to
the ED or see her primary care physician if she develops any symptoms. How is the claim
processed for this encounter?
4
