, Solution manual for Understanding Health
Insurance A Guide to Billing and Reimbursement,
2024 Edition, 19th Edition Michelle A. Green
Notes
1- The file is chapter after chapter.
2- We have shown you few pages sample.
3- The file contains all Appendix and Excel
sheet if it exists.
4- We have all what you need, we make
update at every time. There are many new
editions waiting you.
5- If you think you purchased the wrong file
You can contact us at every time, we can
replace it with true one.
Our email:
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
Solution and Answer Guide
MICHELLE A. GREEN, UNDERSTANDING HEALTH INSURANCE: A GUIDE TO BILLING AND
REIMBURSEMENT: 2024, 19TH EDITION, 9780357932063; CHAPTER 1: HEALTH INSURANCE SPECIALIST CAREER
TABLE OF CONTENTS
Review ..............................................................................................................................................1
1.1: Multiple Choice .................................................................................................................................. 1
1.2: Professionalism .................................................................................................................................. 9
REVIEW
1.1: MULTIPLE CHOICE
1. The document submitted to the payer requesting reimbursement is called a(n)
a. explanation of benefits.
b. health insurance claim.
c. remittance advice.
d. prior approval form.
ANS: b
Analysis:
a. Incorrect. The patient receives an explanation of benefits (EOB) from the third-party payer, which is a
report detailing the results of processing a claim. A health insurance claim is the documentation
submitted to a third-party payer or government program requesting reimbursement for the
health care services provided.
b. Correct. A health insurance claim is the documentation submitted to a third-party payer or
government program requesting reimbursement for the health care services provided.
c. Incorrect. The provider receives a remittance advice (or remit), a notice sent by the insurance company
that contains payment information about a claim.
A health insurance claim is the documentation submitted to a third-party payer or government program
requesting reimbursement for the health care services provided.
d. Incorrect. Many health insurance plans and programs require prior approval for treatment by
specialists and documentation of post-treatment reports, and if the prior approval form is not
submitted prior to treatment, payment of the claim is denied. A health insurance claim is the
documentation submitted to a third-party payer or government program requesting reimbursement
for the health care services provided.
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 1
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
2. The Centers for Medicare and Medicaid Services (CMS) is an administrative agency within the
a. Administration for Children and Families.
b. Department of Health and Human Services.
c. Food and Drug Administration.
d. Office of the Inspector General.
ANS: b
Analysis:
a. Incorrect. The Administration for Children and Families is an administrative agency of the Department
of Health and Human Services. The Centers for Medicare and Medicaid Services is an administrative
agency of the Department of Health and Human Services.
b. Correct. The Centers for Medicare and Medicaid Services is an administrative agency of the
Department of Health and Human Services.
c. Incorrect. The Food and Drug Administration is an administrative agency of the Department of Health
and Human Services. The Centers for Medicare and Medicaid Services is an administrative agency of
the Department of Health and Human Services.
d. Incorrect. The Office of the Inspector General for the Department of Health and Human Services
reports to the Secretary of the Department of Health and Human Services and the United States
Congress. The Centers for Medicare and Medicaid Services is an administrative agency of the
Department of Health and Human Services.
3. A health care practitioner is also called a health care
a. dealer.
b. provider.
c. purveyor.
d. supplier.
ANS: b
Analysis:
a. Incorrect. A health care dealer is an entity that purchases goods for wholesale or retail re-selling,
such as durable medical equipment. A health care provider is a health care practitioner, such as a
physician, physician’s assistance, or nurse practitioner.
b. Correct. A health care provider is a health care practitioner, such as a physician, physician’s
assistance, or nurse practitioner.
c. Incorrect. A health care purveyor refers to an entity that sells or deals in a particular type of
goods. A health care provider is a health care practitioner, such as a physician, physician’s
assistance, or nurse practitioner.
d. Incorrect. A health care supplier is a person or organization that sells or supplies goods, such as
durable medical equipment. A health care provider is a health care practitioner, such as a physician,
physician’s assistance, or nurse practitioner.
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 2
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
4. Which is the most appropriate response to a patient who calls the office and asks to speak with the
physician?
a. Politely state that the physician is busy and cannot be disturbed.
b. Explain that the physician is unavailable and ask if the patient would like to leave a message.
c. Transfer the call to the exam room where the physician is located.
d. Offer to schedule an appointment for the patient to be seen by the physician.
ANS: b
Analysis:
a. Incorrect. Office personnel should not state that the physician is busy and cannot be disturbed.
Office personnel should simply state that the physician is not available and offer to take a
message that will be passed along to the physician when available.
b. Correct. Office personnel should simply state that the physician is not available and offer to take
a message that will be passed along to the physician when available.
c. Incorrect. Unless the physician has specifically requested that a particular patient’s call be forwarded
to the exam room, the patient’s call should be addressed by office personnel. Office personnel should
simply state that the physician is not available and offer to take a message that will be passed along to
the physician when available.
d. Incorrect. The patient may only wish to speak to the physician; however, in many cases, the
patient’s issue may be addressed by the physician or other medical staff (e.g., nurse practitioner,
physician assistant) without the need for a patient appointment. Office personnel should simply
state that the physician is not available and offer to take a message that will be passed along to
the physician when available.
5. The process of assigning diagnoses, procedures, and services using numeric and alphanumeric characters
is called
a. coding.
b. data processing.
c. programming.
d. reimbursement.
ANS: a
Analysis:
a. Correct. Coding involves the assignment of numeric or alphanumeric characters to diagnoses,
procedures, and services.
b. Incorrect. Data processing is the collection and manipulation of data to produce meaningful
information. Coding involves the assignment of numeric or alphanumeric characters to diagnoses,
procedures, and services.
c. Incorrect. Programming is the process of creating executable computer software programs that
instruct the computer to perform specific tasks. Coding involves the assignment of numeric or
alphanumeric characters to diagnoses, procedures, and services.
d. Incorrect. Reimbursement is the payment a provider receives for performing procedures and
providing services or supplies. Coding involves the assignment of numeric or alphanumeric
characters to diagnoses, procedures, and services.
6. If a health insurance plan’s prior approval requirements are not met by providers and the claim is
submitted for reimbursement,
a. administrative costs are reduced.
b. patients’ coverage is cancelled.
c. payment of the claim is denied.
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 3
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
d. they pay a fine to the health plan.
ANS: c
Analysis:
a. Incorrect. Administrative cost actually increase as a result of billing the patient for services
provided, submitting the bill to collections, and writing off the billed amount. If a health insurance
plan’s prior approval requirements are not met by providers and the claim is submitted for
reimbursement, the third-party payer issues claims denials.
b. Incorrect. The patient’s coverage is not cancelled when prior approval requirements are not met. If a
health insurance plan’s prior approval requirements are not met by providers and the claim is
submitted for reimbursement, the patient’s coverage will not be cancelled or impacted but the payer
will deny the claim.
c. Correct. If a health insurance plan’s prior approval requirements are not met by providers and the
claim is submitted for reimbursement, the third-party payer issues claims denials.
d. Incorrect. Providers and patients do not pay a fine to the health plan when prior approval
requirements are not met. If a health insurance plan’s prior approval requirements are not met by
providers and the claim is submitted for reimbursement, the third-party payer issues claims
denials.
7. Which coding system is used to report diagnoses and conditions on claims?
a. CPT
b. HCPCS Level II
c. ICD-10-CM
d. ICD-10-PCS
ANS: c
Analysis:
a. Incorrect. CPT, or Current Procedural Terminology, is used to report procedures or services on
outpatient and physician office claims. ICD-10-CM, or International Classification of Diseases, 10th
Revision, Clinical Modification, is used to report diagnoses and conditions on all claims.
b. Incorrect. HCPCS Level II, or Healthcare Common Procedure Coding System Level II, codes are used to
report procedures or services on outpatient and physician office claims, especially for medical devices
and supplies. ICD-10-CM, or International Classification of Diseases, 10th Revision, Clinical
Modification, is used to report diagnoses and conditions on all claims.
c. Correct. ICD-10-CM, or International Classification of Diseases, 10th Revision, Clinical
Modification, is used to report diagnoses and conditions on all claims.
d. Incorrect. ICD-10-PCS, or International Classification of Diseases, 10th Revision, Procedure Coding
System, is used to report inpatient hospital procedures or services on UB-04 claims. ICD-10-CM, or
International Classification of Diseases, 10th Revision, Clinical Modification, is used to report
diagnoses and conditions on all claims.
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 4
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
8. Which organization publishes the CPT coding system?
a. ADA
b. AHIMA
c. AMA
d. CMS
ANS: c
Analysis:
a. Incorrect. The ADA, or American Dental Association, publishes CDT (Current Dental Terminology).
The AMA, or American Medical Association, publishes CPT (Current Procedural Terminology).
b. Incorrect. AHIMA, or American Health Information Management Association, is a professional
organization that promotes the health information management and coding professions. The
AMA, or American Medical Association, publishes CPT (Current Procedural Terminology).
c. Correct. The AMA, or American Medical Association, publishes CPT (Current Procedural
Terminology).
d. Incorrect. CMS, or Centers for Medicare and Medicaid Services, along with the NCHS (National
Center for Health Statistics) is responsible for developing and updating ICD-10-CM and ICD-10-
PCS. The AMA, or American Medical Association, publishes CPT (Current Procedural Terminology).
9. National codes are associated with
a. CDT.
b. CPT.
c. HCPCS Level II.
d. ICD.
ANS: c
Analysis:
a. Incorrect. CDT, or Current Dental Terminology, codes are assigned for dental services. HCPCS
Level II codes, or National codes, are assigned for outpatient and physician office procedures and
services.
b. Incorrect. CPT, or Current Procedural Terminology, codes are assigned for outpatient and
physician office procedures and services. HCPCS Level II codes, or National codes, are assigned for
outpatient and physician office procedures and services.
c. Correct. HCPCS Level II codes, or National codes, are assigned for outpatient and physician office
procedures and services.
d. Incorrect. ICD, or the International Classification of Diseases, is developed and updated by the
World Health Organization. HCPCS Level II codes, or National codes, are assigned for outpatient
and physician office procedures and services.
10. The process of linking procedure/service and condition codes on a CMS-1500 claim justifies
a. coding.
b. hold harmless.
c. medical necessity.
d. scope of practice.
ANS: c
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 5
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
Analysis:
a. Incorrect. Coding is the process of assigning ICD-10-CM, ICD-10-PCS, CPT, and HCPCS level II codes
to diagnoses, procedures, and services; codes are reported on an insurance claim, and they play
an important role in establishing medical necessity for an encounter. Medical necessity involves
linking every procedure or service code reported on the claim to a condition code that justifies the
need to perform that procedure or service.
b. Incorrect. Hold harmless is an insurance contract clause that states the patient is not responsible for
paying what the insurance plan denies, and the health care provider cannot collect those fees from
the patient. Medical necessity involves linking every procedure or service code reported on the claim
to a condition code that justifies the need to perform that procedure or service.
c. Correct. Medical necessity involves linking every procedure or service code reported on the
claim to a condition code that justifies the need to perform that procedure or service.
d. Incorrect. Scope of practice defines the profession, delineates qualifications and responsibilities, and
clarifies supervision requirements. Medical necessity involves linking every procedure or service code
reported on the claim to a condition code that justifies the need to perform that procedure or
service.
11. The medical practice that employs a health insurance specialist is legally responsible for their actions
when performed within the context of their employment, which is called
a. per se.
b. res gestae.
c. respondeat superior.
d. Subpoena duces tecum.
ANS: c
Analysis:
a. Incorrect. Per se is Latin for “through itself,” which means as such or what would be expected
from a name, such as, “Your opinion about this process is interesting, per se, but it is not relevant
to the current topic.” Respondeat superior is Latin for “let the master answer,” which means that
the employer is liable for the actions and omissions of employees as performed and committed
within the scope of their employment.
b. Incorrect. Res gestae is Latin for “things done” or “things transacted,” which refers to facts in evidence
as part of a litigated issue and are admissible. Respondeat superior is Latin for “let the master
answer,” which means that the employer is liable for the actions and omissions of employees as
performed and committed within the scope of their employment.
c. Correct. Respondeat superior is Latin for “let the master answer,” which means that the
employer is liable for the actions and omissions of employees as performed and committed within
the scope of their employment.
d. Incorrect. Subpoena duces tecum is Latin for “you shall bring with you,” and is a subpoena
(written court order) that requires a witness to produce documents as part of a legal proceeding,
such as patient records. Respondeat superior is Latin for “let the master answer,” which means
that the employer is liable for the actions and omissions of employees as performed and
committed within the scope of their employment.
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 6
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
12. Which type of insurance guarantees repayment for financial losses resulting from an employee’s act or
failure to act?
a. Bonding
b. Liability
c. Property
d. Workers’ compensation
ANS: a
Analysis:
a. Correct. Bonding insurance protects a medical practice from an employee’s act or failure to act.
b. Incorrect. Liability insurance protects a company against third-party lawsuits, such as medical
malpractice lawsuits. Bonding insurance protects a medical practice from an employee’s act or
failure to act.
c. Incorrect. Property insurance protects a company from lawsuits resulting from property owned (e.g.,
visitor or patient fall on a slippery floor). Bonding insurance protects a medical practice from an
employee’s act or failure to act.
d. Incorrect. Workers’ compensation insurance covers employees who are injured or become ill on
the job. Bonding insurance protects a medical practice from an employee’s act or failure to act.
13. Physicians and other health care professionals purchase __________ insurance to protect them from liability
relating to claims arising from patient treatment.
a. bonding
b. medical malpractice
c. third-party payer
d. workers’ compensation
ANS: b
Analysis:
a. Incorrect. Bonding insurance protects a medical practice from an employee’s act or failure to act.
Medical malpractice insurance coverage is purchased to protect the medical practice from third-
party lawsuits alleging medical malpractice or negligence.
b. Correct. Medical malpractice insurance coverage is purchased to protect the medical practice
from third-party lawsuits alleging medical malpractice or negligence.
c. Incorrect. Third-party payer refers to a health plan, health program, or health insurance company
entity that manages and reimburses health care expenses. Medical malpractice insurance
coverage is purchased to protect the medical practice from third-party lawsuits alleging medical
malpractice or negligence.
d. Incorrect. Workers’ compensation insurance covers employees who are injured or become ill on
the job. Medical malpractice insurance coverage is purchased to protect the medical practice
from third-party lawsuits alleging medical malpractice or negligence.
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 7
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
14. Which requires health insurance specialists to differentiate among the technical descriptions of similar
procedures in the CPT coding manual?
a. Critical thinking
b. Data entry
c. Pathophysiology
d. Verbal and written communication
ANS: a
Analysis:
a. Correct. Critical thinking is the process of analyzing information, such as similar CPT code
descriptions to determine the most appropriate code assignment.
b. Incorrect. Data entry is the process of capturing and entering data into medical management
software. Critical thinking is the process of analyzing information, such as similar CPT code
descriptions to determine the most appropriate code assignment.
c. Incorrect. Pathophysiology is the study of the mechanism responsible for a particular disease,
along with etiology, treatments, and outcomes. Critical thinking is the process of analyzing
information, such as similar CPT code descriptions to determine the most appropriate code
assignment.
d. Incorrect. Verbal and written communication is the first step in capturing or gathering
information. Critical thinking is the process of analyzing information, such as similar CPT code
descriptions to determine the most appropriate code assignment.
15. The American Association of Medical Assistants offers which certification exam?
a. CCS
b. CMA
c. CPC
d. RHIT
ANS: b
Analysis:
a. Incorrect. The CCS, or Clinical Coding Specialist, certification exam is offered by the American
Health Information Management Association (AHIMA). The CMA, or Certified Medical Assistant,
certification exam is offered by the American Association of Medical Assistants (AAMA).
b. Correct. The CMA, or Certified Medical Assistant, certification exam is offered by the American
Association of Medical Assistants (AAMA).
c. Incorrect. The CPC, or Certified Professional Coder, certification exam is offered by the AAPC. The
CMA, or Certified Medical Assistant, certification exam is offered by the American Association of
Medical Assistants (AAMA).
d. Incorrect. The RHIT, or Registered Health Information Technician, certification exam is offered by
AHIMA (American Health Information Management Association). The CMA, or Certified Medical
Assistant, certification exam is offered by the American Association of Medical Assistants (AAMA).
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 8
website, in whole or in part.
Insurance A Guide to Billing and Reimbursement,
2024 Edition, 19th Edition Michelle A. Green
Notes
1- The file is chapter after chapter.
2- We have shown you few pages sample.
3- The file contains all Appendix and Excel
sheet if it exists.
4- We have all what you need, we make
update at every time. There are many new
editions waiting you.
5- If you think you purchased the wrong file
You can contact us at every time, we can
replace it with true one.
Our email:
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
Solution and Answer Guide
MICHELLE A. GREEN, UNDERSTANDING HEALTH INSURANCE: A GUIDE TO BILLING AND
REIMBURSEMENT: 2024, 19TH EDITION, 9780357932063; CHAPTER 1: HEALTH INSURANCE SPECIALIST CAREER
TABLE OF CONTENTS
Review ..............................................................................................................................................1
1.1: Multiple Choice .................................................................................................................................. 1
1.2: Professionalism .................................................................................................................................. 9
REVIEW
1.1: MULTIPLE CHOICE
1. The document submitted to the payer requesting reimbursement is called a(n)
a. explanation of benefits.
b. health insurance claim.
c. remittance advice.
d. prior approval form.
ANS: b
Analysis:
a. Incorrect. The patient receives an explanation of benefits (EOB) from the third-party payer, which is a
report detailing the results of processing a claim. A health insurance claim is the documentation
submitted to a third-party payer or government program requesting reimbursement for the
health care services provided.
b. Correct. A health insurance claim is the documentation submitted to a third-party payer or
government program requesting reimbursement for the health care services provided.
c. Incorrect. The provider receives a remittance advice (or remit), a notice sent by the insurance company
that contains payment information about a claim.
A health insurance claim is the documentation submitted to a third-party payer or government program
requesting reimbursement for the health care services provided.
d. Incorrect. Many health insurance plans and programs require prior approval for treatment by
specialists and documentation of post-treatment reports, and if the prior approval form is not
submitted prior to treatment, payment of the claim is denied. A health insurance claim is the
documentation submitted to a third-party payer or government program requesting reimbursement
for the health care services provided.
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 1
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
2. The Centers for Medicare and Medicaid Services (CMS) is an administrative agency within the
a. Administration for Children and Families.
b. Department of Health and Human Services.
c. Food and Drug Administration.
d. Office of the Inspector General.
ANS: b
Analysis:
a. Incorrect. The Administration for Children and Families is an administrative agency of the Department
of Health and Human Services. The Centers for Medicare and Medicaid Services is an administrative
agency of the Department of Health and Human Services.
b. Correct. The Centers for Medicare and Medicaid Services is an administrative agency of the
Department of Health and Human Services.
c. Incorrect. The Food and Drug Administration is an administrative agency of the Department of Health
and Human Services. The Centers for Medicare and Medicaid Services is an administrative agency of
the Department of Health and Human Services.
d. Incorrect. The Office of the Inspector General for the Department of Health and Human Services
reports to the Secretary of the Department of Health and Human Services and the United States
Congress. The Centers for Medicare and Medicaid Services is an administrative agency of the
Department of Health and Human Services.
3. A health care practitioner is also called a health care
a. dealer.
b. provider.
c. purveyor.
d. supplier.
ANS: b
Analysis:
a. Incorrect. A health care dealer is an entity that purchases goods for wholesale or retail re-selling,
such as durable medical equipment. A health care provider is a health care practitioner, such as a
physician, physician’s assistance, or nurse practitioner.
b. Correct. A health care provider is a health care practitioner, such as a physician, physician’s
assistance, or nurse practitioner.
c. Incorrect. A health care purveyor refers to an entity that sells or deals in a particular type of
goods. A health care provider is a health care practitioner, such as a physician, physician’s
assistance, or nurse practitioner.
d. Incorrect. A health care supplier is a person or organization that sells or supplies goods, such as
durable medical equipment. A health care provider is a health care practitioner, such as a physician,
physician’s assistance, or nurse practitioner.
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 2
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
4. Which is the most appropriate response to a patient who calls the office and asks to speak with the
physician?
a. Politely state that the physician is busy and cannot be disturbed.
b. Explain that the physician is unavailable and ask if the patient would like to leave a message.
c. Transfer the call to the exam room where the physician is located.
d. Offer to schedule an appointment for the patient to be seen by the physician.
ANS: b
Analysis:
a. Incorrect. Office personnel should not state that the physician is busy and cannot be disturbed.
Office personnel should simply state that the physician is not available and offer to take a
message that will be passed along to the physician when available.
b. Correct. Office personnel should simply state that the physician is not available and offer to take
a message that will be passed along to the physician when available.
c. Incorrect. Unless the physician has specifically requested that a particular patient’s call be forwarded
to the exam room, the patient’s call should be addressed by office personnel. Office personnel should
simply state that the physician is not available and offer to take a message that will be passed along to
the physician when available.
d. Incorrect. The patient may only wish to speak to the physician; however, in many cases, the
patient’s issue may be addressed by the physician or other medical staff (e.g., nurse practitioner,
physician assistant) without the need for a patient appointment. Office personnel should simply
state that the physician is not available and offer to take a message that will be passed along to
the physician when available.
5. The process of assigning diagnoses, procedures, and services using numeric and alphanumeric characters
is called
a. coding.
b. data processing.
c. programming.
d. reimbursement.
ANS: a
Analysis:
a. Correct. Coding involves the assignment of numeric or alphanumeric characters to diagnoses,
procedures, and services.
b. Incorrect. Data processing is the collection and manipulation of data to produce meaningful
information. Coding involves the assignment of numeric or alphanumeric characters to diagnoses,
procedures, and services.
c. Incorrect. Programming is the process of creating executable computer software programs that
instruct the computer to perform specific tasks. Coding involves the assignment of numeric or
alphanumeric characters to diagnoses, procedures, and services.
d. Incorrect. Reimbursement is the payment a provider receives for performing procedures and
providing services or supplies. Coding involves the assignment of numeric or alphanumeric
characters to diagnoses, procedures, and services.
6. If a health insurance plan’s prior approval requirements are not met by providers and the claim is
submitted for reimbursement,
a. administrative costs are reduced.
b. patients’ coverage is cancelled.
c. payment of the claim is denied.
0
© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 3
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
d. they pay a fine to the health plan.
ANS: c
Analysis:
a. Incorrect. Administrative cost actually increase as a result of billing the patient for services
provided, submitting the bill to collections, and writing off the billed amount. If a health insurance
plan’s prior approval requirements are not met by providers and the claim is submitted for
reimbursement, the third-party payer issues claims denials.
b. Incorrect. The patient’s coverage is not cancelled when prior approval requirements are not met. If a
health insurance plan’s prior approval requirements are not met by providers and the claim is
submitted for reimbursement, the patient’s coverage will not be cancelled or impacted but the payer
will deny the claim.
c. Correct. If a health insurance plan’s prior approval requirements are not met by providers and the
claim is submitted for reimbursement, the third-party payer issues claims denials.
d. Incorrect. Providers and patients do not pay a fine to the health plan when prior approval
requirements are not met. If a health insurance plan’s prior approval requirements are not met by
providers and the claim is submitted for reimbursement, the third-party payer issues claims
denials.
7. Which coding system is used to report diagnoses and conditions on claims?
a. CPT
b. HCPCS Level II
c. ICD-10-CM
d. ICD-10-PCS
ANS: c
Analysis:
a. Incorrect. CPT, or Current Procedural Terminology, is used to report procedures or services on
outpatient and physician office claims. ICD-10-CM, or International Classification of Diseases, 10th
Revision, Clinical Modification, is used to report diagnoses and conditions on all claims.
b. Incorrect. HCPCS Level II, or Healthcare Common Procedure Coding System Level II, codes are used to
report procedures or services on outpatient and physician office claims, especially for medical devices
and supplies. ICD-10-CM, or International Classification of Diseases, 10th Revision, Clinical
Modification, is used to report diagnoses and conditions on all claims.
c. Correct. ICD-10-CM, or International Classification of Diseases, 10th Revision, Clinical
Modification, is used to report diagnoses and conditions on all claims.
d. Incorrect. ICD-10-PCS, or International Classification of Diseases, 10th Revision, Procedure Coding
System, is used to report inpatient hospital procedures or services on UB-04 claims. ICD-10-CM, or
International Classification of Diseases, 10th Revision, Clinical Modification, is used to report
diagnoses and conditions on all claims.
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website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
8. Which organization publishes the CPT coding system?
a. ADA
b. AHIMA
c. AMA
d. CMS
ANS: c
Analysis:
a. Incorrect. The ADA, or American Dental Association, publishes CDT (Current Dental Terminology).
The AMA, or American Medical Association, publishes CPT (Current Procedural Terminology).
b. Incorrect. AHIMA, or American Health Information Management Association, is a professional
organization that promotes the health information management and coding professions. The
AMA, or American Medical Association, publishes CPT (Current Procedural Terminology).
c. Correct. The AMA, or American Medical Association, publishes CPT (Current Procedural
Terminology).
d. Incorrect. CMS, or Centers for Medicare and Medicaid Services, along with the NCHS (National
Center for Health Statistics) is responsible for developing and updating ICD-10-CM and ICD-10-
PCS. The AMA, or American Medical Association, publishes CPT (Current Procedural Terminology).
9. National codes are associated with
a. CDT.
b. CPT.
c. HCPCS Level II.
d. ICD.
ANS: c
Analysis:
a. Incorrect. CDT, or Current Dental Terminology, codes are assigned for dental services. HCPCS
Level II codes, or National codes, are assigned for outpatient and physician office procedures and
services.
b. Incorrect. CPT, or Current Procedural Terminology, codes are assigned for outpatient and
physician office procedures and services. HCPCS Level II codes, or National codes, are assigned for
outpatient and physician office procedures and services.
c. Correct. HCPCS Level II codes, or National codes, are assigned for outpatient and physician office
procedures and services.
d. Incorrect. ICD, or the International Classification of Diseases, is developed and updated by the
World Health Organization. HCPCS Level II codes, or National codes, are assigned for outpatient
and physician office procedures and services.
10. The process of linking procedure/service and condition codes on a CMS-1500 claim justifies
a. coding.
b. hold harmless.
c. medical necessity.
d. scope of practice.
ANS: c
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website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
Analysis:
a. Incorrect. Coding is the process of assigning ICD-10-CM, ICD-10-PCS, CPT, and HCPCS level II codes
to diagnoses, procedures, and services; codes are reported on an insurance claim, and they play
an important role in establishing medical necessity for an encounter. Medical necessity involves
linking every procedure or service code reported on the claim to a condition code that justifies the
need to perform that procedure or service.
b. Incorrect. Hold harmless is an insurance contract clause that states the patient is not responsible for
paying what the insurance plan denies, and the health care provider cannot collect those fees from
the patient. Medical necessity involves linking every procedure or service code reported on the claim
to a condition code that justifies the need to perform that procedure or service.
c. Correct. Medical necessity involves linking every procedure or service code reported on the
claim to a condition code that justifies the need to perform that procedure or service.
d. Incorrect. Scope of practice defines the profession, delineates qualifications and responsibilities, and
clarifies supervision requirements. Medical necessity involves linking every procedure or service code
reported on the claim to a condition code that justifies the need to perform that procedure or
service.
11. The medical practice that employs a health insurance specialist is legally responsible for their actions
when performed within the context of their employment, which is called
a. per se.
b. res gestae.
c. respondeat superior.
d. Subpoena duces tecum.
ANS: c
Analysis:
a. Incorrect. Per se is Latin for “through itself,” which means as such or what would be expected
from a name, such as, “Your opinion about this process is interesting, per se, but it is not relevant
to the current topic.” Respondeat superior is Latin for “let the master answer,” which means that
the employer is liable for the actions and omissions of employees as performed and committed
within the scope of their employment.
b. Incorrect. Res gestae is Latin for “things done” or “things transacted,” which refers to facts in evidence
as part of a litigated issue and are admissible. Respondeat superior is Latin for “let the master
answer,” which means that the employer is liable for the actions and omissions of employees as
performed and committed within the scope of their employment.
c. Correct. Respondeat superior is Latin for “let the master answer,” which means that the
employer is liable for the actions and omissions of employees as performed and committed within
the scope of their employment.
d. Incorrect. Subpoena duces tecum is Latin for “you shall bring with you,” and is a subpoena
(written court order) that requires a witness to produce documents as part of a legal proceeding,
such as patient records. Respondeat superior is Latin for “let the master answer,” which means
that the employer is liable for the actions and omissions of employees as performed and
committed within the scope of their employment.
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© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 6
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
12. Which type of insurance guarantees repayment for financial losses resulting from an employee’s act or
failure to act?
a. Bonding
b. Liability
c. Property
d. Workers’ compensation
ANS: a
Analysis:
a. Correct. Bonding insurance protects a medical practice from an employee’s act or failure to act.
b. Incorrect. Liability insurance protects a company against third-party lawsuits, such as medical
malpractice lawsuits. Bonding insurance protects a medical practice from an employee’s act or
failure to act.
c. Incorrect. Property insurance protects a company from lawsuits resulting from property owned (e.g.,
visitor or patient fall on a slippery floor). Bonding insurance protects a medical practice from an
employee’s act or failure to act.
d. Incorrect. Workers’ compensation insurance covers employees who are injured or become ill on
the job. Bonding insurance protects a medical practice from an employee’s act or failure to act.
13. Physicians and other health care professionals purchase __________ insurance to protect them from liability
relating to claims arising from patient treatment.
a. bonding
b. medical malpractice
c. third-party payer
d. workers’ compensation
ANS: b
Analysis:
a. Incorrect. Bonding insurance protects a medical practice from an employee’s act or failure to act.
Medical malpractice insurance coverage is purchased to protect the medical practice from third-
party lawsuits alleging medical malpractice or negligence.
b. Correct. Medical malpractice insurance coverage is purchased to protect the medical practice
from third-party lawsuits alleging medical malpractice or negligence.
c. Incorrect. Third-party payer refers to a health plan, health program, or health insurance company
entity that manages and reimburses health care expenses. Medical malpractice insurance
coverage is purchased to protect the medical practice from third-party lawsuits alleging medical
malpractice or negligence.
d. Incorrect. Workers’ compensation insurance covers employees who are injured or become ill on
the job. Medical malpractice insurance coverage is purchased to protect the medical practice
from third-party lawsuits alleging medical malpractice or negligence.
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© 2025 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible 7
website, in whole or in part.
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
14. Which requires health insurance specialists to differentiate among the technical descriptions of similar
procedures in the CPT coding manual?
a. Critical thinking
b. Data entry
c. Pathophysiology
d. Verbal and written communication
ANS: a
Analysis:
a. Correct. Critical thinking is the process of analyzing information, such as similar CPT code
descriptions to determine the most appropriate code assignment.
b. Incorrect. Data entry is the process of capturing and entering data into medical management
software. Critical thinking is the process of analyzing information, such as similar CPT code
descriptions to determine the most appropriate code assignment.
c. Incorrect. Pathophysiology is the study of the mechanism responsible for a particular disease,
along with etiology, treatments, and outcomes. Critical thinking is the process of analyzing
information, such as similar CPT code descriptions to determine the most appropriate code
assignment.
d. Incorrect. Verbal and written communication is the first step in capturing or gathering
information. Critical thinking is the process of analyzing information, such as similar CPT code
descriptions to determine the most appropriate code assignment.
15. The American Association of Medical Assistants offers which certification exam?
a. CCS
b. CMA
c. CPC
d. RHIT
ANS: b
Analysis:
a. Incorrect. The CCS, or Clinical Coding Specialist, certification exam is offered by the American
Health Information Management Association (AHIMA). The CMA, or Certified Medical Assistant,
certification exam is offered by the American Association of Medical Assistants (AAMA).
b. Correct. The CMA, or Certified Medical Assistant, certification exam is offered by the American
Association of Medical Assistants (AAMA).
c. Incorrect. The CPC, or Certified Professional Coder, certification exam is offered by the AAPC. The
CMA, or Certified Medical Assistant, certification exam is offered by the American Association of
Medical Assistants (AAMA).
d. Incorrect. The RHIT, or Registered Health Information Technician, certification exam is offered by
AHIMA (American Health Information Management Association). The CMA, or Certified Medical
Assistant, certification exam is offered by the American Association of Medical Assistants (AAMA).
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