CCMA insurance claims and billing codes practice questions, with every answer explained

1. UB-04
2. Form W-2
3. CMS-1500
4. Form I-9

Answer: C. The CMS-1500 is the standard professional claim form; its electronic equivalent is the 837P transaction. The UB-04 (CMS-1450) is used for institutional claims such as hospitals.

Why not A: UB-04 is for institutional facilities.

Why not B: A W-2 is an employee tax form.

Why not D: An I-9 verifies employment eligibility.

Exam tactic: Office/professional = CMS-1500. Hospital/institutional = UB-04.

1. The two terms mean exactly the same thing to a payer
2. Rejected means the claim was paid, but at a lower rate
3. Rejected failed edits and wasn't processed; denied was processed, not paid
4. Denied was never received by the payer; rejected was paid

Answer: C. Rejected claims fail front-end checks (for example, a missing ID or invalid code) and are corrected and resubmitted. Denied claims were adjudicated and payment was refused; they may be corrected and resubmitted or appealed depending on the reason.

Why not A: The terms have different meanings and different fixes.

Why not B: A rejected claim is not paid at all.

Why not D: A denied claim was received and adjudicated.

Exam tactic: Rejected = fix and resend. Denied = review, correct, or appeal.

1. A unique 10-digit number identifying the provider
2. The patient's insurance member number
3. A code that identifies the patient's diagnosis
4. The provider's state medical license number

Answer: A. The NPI is a unique 10-digit identifier assigned to health care providers and organizations under HIPAA, required on standard electronic transactions and claims.

Why not B: The member number identifies the patient's coverage.

Why not C: Diagnoses are identified by ICD-10-CM codes.

Why not D: State license numbers are separate credentials.

Exam tactic: NPI = 10 digits, identifies the provider.

1. To show a service was changed by a specific circumstance
2. To replace the diagnosis code on the claim form
3. To increase the fee automatically in every case
4. To identify the patient's insurance plan type

Answer: A. Modifiers are two-character codes that add information, such as a bilateral procedure, a distinct service, or a reduced service. They must be supported by documentation.

Why not B: Modifiers do not replace diagnosis codes.

Why not C: Modifiers do not automatically increase payment.

Why not D: Insurance plans are identified elsewhere on the claim.

Exam tactic: Modifier = extra detail, not extra money.

1. It makes the claim form shorter and easier to read
2. It shows the payer the service was medically necessary
3. It is optional for most commercial insurance payers
4. It only matters for patients who pay out of pocket

Answer: B. Payers link each service to a diagnosis to confirm medical necessity. A mismatched or unsupported diagnosis commonly leads to denial.

Why not A: Claim length is not the reason.

Why not C: Diagnosis linkage is required by payers.

Why not D: Self-pay patients do not generate insurance claims.

Exam tactic: Diagnosis justifies the procedure.

1. A form patients use to request records
2. An insurance card from a secondary plan
3. The patient's final statement after insurance pays
4. A form listing the services, codes, and charges for a patient visit

Answer: D. The superbill lists common procedures and diagnoses with codes and fees. The provider marks services performed, and it is used to post charges and create the claim. Many practices now use electronic charge capture.

Why not A: Records requests use an authorization form.

Why not B: Insurance cards identify coverage.

Why not C: The final statement is sent to the patient after adjudication.

Exam tactic: Superbill = the visit's charge ticket.

1. The provider to release records to anyone
2. The patient to skip the copay
3. The insurer to pay the provider directly
4. The insurer to raise the patient's premium

Answer: C. Assignment of benefits authorizes the insurance company to send payment directly to the provider. A separate authorization covers release of information needed to process the claim.

Why not A: Release of information is a different authorization.

Why not B: Copays are still owed.

Why not D: Premiums are not affected by this form.

Exam tactic: Assignment = pay the doctor directly.

1. There are no filing deadlines for insurance claims
2. The filing limit only applies to paper claim forms
3. Late claims are paid at a higher rate for the delay
4. Late claims can be denied and often can't be billed to the patient

Answer: D. Each payer sets a deadline for claim submission. For Medicare, it is generally one calendar year from the date of service. Missing it usually results in denial, and contracts often prohibit billing the patient for the provider's late filing.

Why not A: Payers do set filing limits.

Why not B: Deadlines apply to electronic and paper claims.

Why not C: Late claims are denied, not paid more.

Exam tactic: Know each payer's deadline. Late = lost.

1. The specialty of the treating provider
2. The type of insurance plan billed
3. Where the service was provided, like an office
4. The patient's home address and ZIP code

Answer: C. The place of service (POS) code identifies the setting where the service was performed, such as the office (POS 11), because payment can differ by setting.

Why not A: Specialty is identified through provider enrollment and taxonomy codes.

Why not B: Plan type is identified by the payer information.

Why not D: The patient's address is reported separately.

Exam tactic: POS = where the service happened.

1. Write off the entire charge as uncollectible
2. Resubmit the same claim unchanged until it goes through
3. Bill the patient the full amount right away
4. Verify the correct data, fix it, and resubmit

Answer: D. Demographic mismatches are among the most common rejections. The information is verified, corrected in the system, and the claim resubmitted promptly.

Why not A: A correctable error does not justify writing off the charge.

Why not B: Resending the same error will be rejected again.

Why not C: The patient should not be billed for an insurer rejection that can be corrected.

Exam tactic: Rejection for demographics: verify, fix, resend.