1. The information for Blocks 1–9 on the CMS-1500 can be obtained from the A. ledger card. B. medical treatment record. C. confidential patient information record. D. fee schedule. 2. If a patient is covered by Medicaid, what should you put in Block #9a? A. Nothing B. The 12-digit Medicaid number C. The policy number of other coverage, if any D. The patient’s social security number Lessons 2 and 3 Insurance Form Preparation Exam 2 When you feel confident that you have mastered the material in Lessons 2 and 3, go to http://www. takeexamsonline. com and submit your answers online.

If you don’t have access to the Internet, you can phone in or mail in your exam. If you’re unable to take the exam by telephone or online, please call Student Services and request the special answer sheet and mail in your exam. Submit your answers for this examination as soon as you complete it. Do not wait until another examination is ready. Questions 1–45: Select the one best answer to each question. EXAMINATION NUMBER: 38181803 Whichever method you use in submitting your exam answers to the school, you must use the number above. For the quickest test results, go to http://www. takeexamsonline. com Examination . If both nondivorced parents of a dependent child have insurance that will cover the child, which policy is considered to be the primary carrier for the child? A. The mother’s insurance B. The father’s insurance C. The coverage that has been in effect longer D. The coverage of the parent whose birthday falls earlier in the year 4. As an employee at Medical & Dental Associates, how much should you charge for comprehensive service for an established patient? A. $48 C. $72 B. $55 D. $90 5. A type of insurance that was designed to meet the needs of senior citizens is A. Medicare. C. CHAMPUS. B. Medicaid.

D. SSI. 6. CHAMPVA would be considered a primary payer for a patient who has _______ coverage. A. Medicaid C. Medicare B. fee-for-service D. SSI 7. You should record payments that are received from insurance companies on the A. confidential patient information record. B. medical treatment record. C. routing slip. D. ledger card. 8. When filling out a CMS-1500 form, where would you place the address of the agency to which you’re submitting the form? A. At the very top right of the form C. In Block #5 B. On the EOB D. In Block #9d 9. Suppose that your office has submitted a claim for $800 to Medicare.

The amount approved by Medicare for this claim is $625. How much will your office actually receive from Medicare? A. $175 C. $625 B. $500 D. $800 10. When should you submit a claim to a secondary insurance company? A. When a primary insurance company returns a claim for correction B. When the patient authorizes you to do so C. At the same time you submit the claim to the primary carrier D. After you receive payment from the primary insurance company 11. If the patient in Question 9 has only Medicare coverage, your office will have to bill the patient for the amount of A. $125. C. $300.

B. $175. D. $625. 12. When you’re completing a CMS-1500 form for a fee-for-service insurance company, you should omit the patient’s telephone number because A. a patient’s phone number is confidential information. B. the insurance company will already have the patient’s number. C. the insurance company shouldn’t contact the patient directly by phone. D. the phone number creates problems for scanners. 13. Most of the laws that govern Medicaid coverage are set by A. the CMS. C. state governments. B. WHO. D. the federal government. 14. The purpose of Coordination of Benefits clauses is to

A. avoid overpayments of insurance claims. B. make the completion of the CMS-1500 easier. C. outline the order in which insurance companies are to be billed. D. make sure that physicians receive 100 percent of what they charge. 15. One of the physicians in your office is treating Karen Roberts for a work-related injury. Karen will be receiving workers’ compensation for her injury. Who should receive the claim for any treatment Karen receives that’s not related to the work injury? A. Karen’s employer B. Workers’ compensation C. Medicare D. Karen’s primary insurance company 16.

CHAMPUS was created to provide insurance coverage primarily for A. men and women on active duty in the armed forces. B. spouses and children of men and women on active duty. C. disabled veterans. D. retired veterans. 17. In Block #8 of the CMS-1500 form, the box labeled “full-time student” and “part-time student” is used for A. patients who are dependent children of the subscriber. B. patients under the age of 18. C. patients who are at the age of majority but are still covered by their parents’ insurance. D. patients who are dependent children with their own insurance coverage. 18.

What form should be attached to a CMS-1500 form submitted to a secondary insurance company? A. A copy of the CMS-1500 sent to the primary insurance company B. An Explanation of Benefits C. A copy of the patient’s medical treatment record D. A copy of the patient’s ledger card 19. The type of insurance that’s most often prone to abuse is A. auto liability. C. Medicare. B. workers’ compensation. D. fee-for-service. 20. What is a type of insurance policy outlining the benefits to be paid for each type of service normally based on the usual and customary rates (UCR) for each community? A. Disability insurance C. Fee-for-service

B. SSDI D. SSI 21. Which of the following blocks on the CMS-1500 must be completed for indemnity insurance? A. Block #19 C. Block #21 B. Block #20 D. Block #23 22. In a workers’ compensation case, who determines the date when the employee is expected to return to work? A. The insurance company representative B. The employer C. The employee D. The physician 23. To provide nonemergency treatment to a CHAMPUS patient, the sponsor must obtain preauthorization if the A. patient is new to the office. B. sponsor is within a 40-mile radius of a CHAMPUS treatment facility. C. patient has secondary insurance coverage.

D. sponsor is treating the patient for an injury caused by an automobile accident. Questions 24, 25, 26, and 27 are based on the CPIR and the Medical Treatment Record for Maria Blumquist found on pages 192 and 193 in your textbook. 24. What number should you insert in Block #1a of the CMS-1500 form you prepare for patient Blumquist? A. 34113-6006-2 C. 99-9999999 B. 309-14-1688 D. 317-555-3060 25. Which of the following amounts will you insert in Block #28? A. $55 C. $60 B. $75 D. $70 26. Which of the following codes should you include in Block #21? A. 802. 20 C. 99204 B. 802. 30 D. J9293 27.

Which of the following boxes should you check in Block #6? A. Self C. Child B. Spouse D. Other Questions 28 and 29 are based on the CPIR and the routing slip for Hoyt Styvesant found on pages 216 and 217 in your textbook. 28. In preparing a CMS-1500 form for Mr. Styvesant, which of the following numbers should you insert in Block #21, line 1? A. 295. 70 C. 99211 B. 786. 50 D. J1631 29. How should you handle Block #9a? A. Insert 334092121C4. C. Insert 334-90-2121. B. Leave it blank. D. Insert 3175556181. Questions 30, 31, 32, 33, and 34 are based on Record #13, Sheets 1–3, on pages 204–206 in your textbook. 30.

Which of the following numbers should you insert in Block #1a on the CMS-1500 form that you submit to the primary insurance company? A. 400-91-6724 C. 391-61-3206 B. 389416707 D. 311186240 31. If you receive $40 from the primary insurance company and $15 from the secondary insurance carrier, how much should you submit to the third carrier? A. Nothing C. $48 B. $13 D. $68 32. Which of the following numbers should you place in Block #24-E? A. 1 C. 99214 B. 2 D. 90704 33. According to Medical & Dental Associates’ procedures, who should receive the bill for the portion of Ritchey’s fee that’s not covered by insurance?

A. Ritchey Bacon C. Cheryl Bacon B. Melanie Beeker D. Charles Bacon 34. Under how many insurance policies is Ritchey covered? A. 1 C. 3 B. 2 D. 4 Questions 35, 36, 37, 38, and 39 are based on the CPIR and the routing slip for Philip Woods found on pages 222 and 223 in your textbook. 35. In preparing a CMS-1500 form for patient Woods, which of the following codes should you use for the primary diagnosis? A. 99243 C. 571. 5 B. 80059 D. 599. 7 36. Which of the following actions should you take for Block #24K? A. Leave Block #24K blank. B. Get the correct number for Block #24K from the Medicaid office.

C. Place code number 477090032 in Block #24K. D. Place code number 218603419 in Block #24K. 37. Which of the following is the total amount of the bill you should submit to Medicaid for Philip Woods? A. $69 C. $194 B. $81 D. $206 38. When you receive the Medicaid payment for Philip Woods, which of the following actions should you take regarding the remainder of the bill? A. Send no more claims—you must accept what Medicaid provides. B. Send a bill for the remainder to the patient, Philip Woods. C. Submit a second claim to Medicare. D. Submit a claim to the referring doctor, Dr. Lukoskie. 39.

Philip Woods was charged the amount of $45 for a A. hepatic function panel. C. hepatitis panel. B. general health panel. D. quantitative syphilis test. Questions 40, 41, and 42 are based on the CPIR and two routing slips for Keith Konklin found on pages 240–242 in your textbook. 40. On the ADA for Keith Konklin, the number 333-2589 should be placed in Block A. #7. C. #19. B. #18. D. #31. 41. Which of the following is the total amount of the claim to be submitted for patient Konklin? A. $475 C. $579 B. $554 D. $683 42. Which of the following codes should include an indication of tooth 14 on the ADA? A. 02330 C. 00220 B. 00120 D. 1110 Question 43 is based on the CPIR and routing slip for Terrence James found on pages 245 and 246 in your textbook. 43. Which of the following types of insurance form should you complete for Terence James? A. An ADA form B. A CMS-1500 form C. A form provided by the patient D. A Medicaid Dental form Questions 44 and 45 are based on the CPIR and routing slip for Bill Williams found on pages 247 and 248 in your textbook. 44. How many separate items should you list in Block #31? A. 1 C. 4 B. 2 D. 5 45. For Blocks #24–#30, which one should be marked “yes” for Bill Williams? A. BlockC. Block #27 B. Block #25 D. Block #28