PTCB Billing and Reimbursement Practice Test

These questions are part of the practice quiz. Start practicing

• Dual eligible refers to patients who are eligible for which coverage?
• Annual Wellness Visit is primarily designed for which population?
• What does RPM stand for in healthcare billing and reimbursement?
• Which of the following is a function of DUR?
• Chronic Care Management (CCM) requires 2 or more chronic conditions expected to last for how long?
• In the described measure, what is being measured over the total population?
• J codes are used for which type of drugs?
• Which of the following is an example of a prior approval type?
• In audit terminology, a validation audit is used to:
• Co-insurance is defined as
• Which plan is more restrictive than a PPO and makes providers outside the plan the patient's full financial responsibility?
• Which plan is funded by an employer and typically administered by a health insurance company?
• In drug claim submissions, which identifier is used for the pharmacy?
• MACs are responsible for which functions?
• Which items are required for drug claim submission under patient/prescriber info?
• Which entity is responsible for the audit data response timeframe described?
• Which plan is commonly designed to provide flexibility by allowing out-of-network care at higher costs while maintaining an in-network option?
• The Physician Fee Schedule describes service fees that must be the same for all patients and requires a public listing of common services.
• The concept of 'anatomy of a measure' in quality metrics refers to:
• Which organization is commonly referred to as the Medicare Benefits Manager in the context of Medicare and Medicaid?
• HCPCS Level I and Level II codes differ in which way?
• Incident-to services require which type of supervision?
• MACs primarily handle which activities?
• What is the primary reason for a prior approval process?
• Which of the following is a TJC accreditation program category?
• RBRVS stands for which of the following?
• Which statement best describes compliance in the Medicare context?
• HRSA focuses on improving access to healthcare for which populations?
• Which organization requires audit data within the specified timeframe after a request?
• Low Income Subsidy automatic enrollment occurs for individuals who are on Supplemental Security Income (SSI) or who are...
• What is the typical time frame for an electronic prior authorization decision?
• What is the unique ten-digit identification number required by HIPAA for all health care providers?
• HCPCS Level 1 codes correspond to which coding system?
• In PBM claim adjudication, which step confirms that the prescribed medication is included on the member's formulary?
• Which of the following is NOT a 340B covered entity?
• Which plan allows a patient to choose an HMO or non-HMO provider but requires a deductible for non-HMO visits?
• Deductible is
• What is CPPA's stated mission?
• CPT code 99605 corresponds to which service?
• Which of the following topics is not described in the material?
• How is fraud defined in healthcare billing?
• E codes are associated with which category in the provided material?
• Dispensing Fee is defined as
• In PBM claim adjudication, which step triggers safety alerts such as drug interactions?
• Which plan allows participants to see any provider with reimbursement as expenses incurred?
• The initiation of a validation audit is typically counted from:
• Which term best completes this statement: A formulary often uses tiers to categorize products; the common word for these categories is ____?
• Ambulatory Payment Classification (APC) groups are used to determine payments for which setting?
• Which term refers to medications approved only for specific clinical situations and may trigger PA?
• Co-pay is defined as
• What is the purpose of Coordination of Benefits (COB) procedures?
• In hospital settings, which level of supervision is typically required?
• What is the primary goal of the 340B program?
• Transitional care management includes services following discharge from which settings?
• Which item is listed as a reason for prior authorization rejection?
• Which documentation helps avoid audits in the context of prior authorization-related billing?
• CMS rules include determinations of what concepts?
• Which CPPA accreditation program focuses on remote healthcare delivery via technology?
• Which statement best describes the time requirements for basic and complex CCM?
• What is step therapy in the PA process?
• Which statement best distinguishes co-pay from deductible?
• Which statement best reflects the definition of quality in healthcare?
• Measuring adherence rates in Medicare Part D primarily assesses:
• In medical billing, which identifier uniquely identifies a healthcare provider?
• Which law is known as the Physician Self-Referral Law (Stark Law)?
• What is the purpose of an audit in healthcare billing?
• What does DAW indicate on a prescription claim?
• Which plan is typically described as having enrollment through a network of providers with care coordinated by a gatekeeper?
• Which plan requires use of network providers with no coverage outside except emergencies, and uses a gatekeeper primary care physician?
• Which data elements are typically included to determine patient cost on a drug claim?
• Who is responsible for the 340B drug discount program?
• How is abuse defined in Medicare billing?
• The universe submission deadline refers to providing requested data within how many days of the engagement letter?
• What is the Inspector General responsible for?
• Revenue code 0250 corresponds to which category?
• Which of the following is a 340B covered entity category?
• URAC is best described as
• Medicaid's federal matching rate for state funding is approximately what percent on average?
• Which CPPA accreditation programs are offered?
• Revenue code 0250 is used for which category?
• A response to an audit finding results in which type of audit?
• In formulary management, what does step therapy require?
• Diabetes Self Management Training (DSMT) requires accreditation from which organizations?
• A tier system usually differentiates between how many tiers?
• HCPCS stands for what?
• Which statement best describes a formulary?
• In an audit, what does the universe submission refer to?
• Which pricing term represents the list price at which the manufacturer sells the drug to the wholesaler?
• What does PCM stand for in the course material?
• Drug Utilization Review (DUR) is used to
• The Office of Inspector General responsible for Medicare program audits and investigations operates under which department?
• In what year was NCQA re-established as a private independent nonprofit healthcare quality oversight organization?
• Which of the following is a TJC certification program category?
• The post-audit action described is intended to verify that corrective actions address the finding, which is a:
• What does the NPI stand for in the HIPAA context?
• Which statement defines Average actual cost (AAC)?
• In PBM claim adjudication, which step determines the amount of the patient's price?
• Which term describes an audit conducted remotely without a site visit?
• A validation audit occurs within how many days of a finding?
• HEDIS is best described as
• Which scenario is a reason medications typically require prior authorization?
• Which agency is responsible for improving healthcare access for geographically isolated or vulnerable populations?
• Donabedian's model components include structure, process, and which?
• Which plan provides coverage through a network of selected providers but may require higher costs for care received outside the network?
• Which term represents the list price the manufacturer sells to wholesalers?
• Quality Assurance is best described as
• Which term describes the pharmacy's retail price for a medication that they would charge to a cash paying customer?
• Which statement best describes claims processing or adjudication?
• HCPCS Level II codes cover codes for what?
• What does NDC stand for in drug claims?
• What does quantity limits (QL) refer to in prescription coverage?
• Revenue code 0637 corresponds to which category?
• The purpose of measuring adherence rates in this context is to:
• Which term describes the maximum price per tablet that an insurer or PBM will pay for a given product?
• Which revenue code is associated with drugs requiring detailed coding, including radionuclides, vaccines, toxoids, immune globulins, and blood factors?
• What is the billing unit for procedures or vaccinations?
• Which plan is designed to reduce premium costs by requiring a higher deductible before benefits start?
• What does CPPA stand for?
• FUL is defined as
• Adherence rates in Medicare Part D are an example of which type of measure?
• Quality measures can assess which of the following aspects of care?
• Which term is derived from the sales from manufacturers to all purchasers?
• Which of the following is a TJC accreditation program category?
• Under the duplicate discount prohibition, a covered entity may receive rebates from drug manufacturers and Medicaid rebates simultaneously.
• In what year did NCQA originally focus on reviewing PPO and HMO plans when it was founded in 1979?
• AMP is associated with which part of the supply chain?
• Who reviews to determine if an audit is ready to move to the Close out phase?
• What is a Pharmacy Benefit Manager (PBM)?
• G codes are used to represent which category of procedures?
• Which statement about the Joint Commission is accurate?
• Which plan provides coverage through a network of selected providers, but allows out-of-network visits with higher costs?
• Which plan type pays the Medicare deductibles, copayments, and other expenses for Medicare Part A and B?
• Which PA channel yields the fastest decision times?
• FQHC stands for which type of health center?
• Which describes the medication information needed for PA?
• Why is accreditation important to payers?
• In insurer information, what does RxPCN stand for?
• Which plan is specifically described as Medicare coverage for expenses not paid by Part A or Part B?
• Which system is used to determine how much providers should be paid for services rendered and is used by Medicare and many other health insurance companies?
• Which organization is the Medicare Benefits Manager (the entity that administers Medicare benefits)?
• Which describes the prescription adjudication process?
• URAC's role includes offering quality benchmark programs to improve quality and accountability of health care organizations. Which statement best matches this?
• The Low Income Subsidy is intended to help with what?
• Which statement best describes the Physician Fee Schedule?
• Annual Wellness Visit (AWV) provides which of the following?
• Which of the following laws is not listed as addressing Medicare fraud and abuse in this context?
• What is accreditation?
• Which set of beneficiary information is typically required for a PA?
• Which of the following is NOT a type of quality measure?
• What is the formulary?
• Tier system is a method to differentiate within the formulary; usually 3-5 tiers.
• Which organization accredits critical access hospitals and hospitals?
• Revenue code 0636 is associated with which description?
• Self-administrable drugs refer to which description?
• Which plan requires paying a higher deductible to cover medical expenses before insurance payments begin?
• Who is responsible for audits in the Federal Government?
• What is a Compliance Officer?
• Which stage in the audit process involves validating findings and closing out the audit?
• The 340B program requires drug manufacturers to provide outpatient drugs at a reduced price to certain covered entities.
• Which laws address Medicare fraud and abuse?
• RBRVS is used to determine payments for physician services. Which option best reflects this system?
• Which statement defines Average Wholesale Price (AWP)?
• Which statement best describes step therapy in practice?
• Which statement best describes provider information commonly needed for PA?
• What is alternative substitution in the context of payer drug coverage?
• What is the typical time frame to obtain a prior authorization decision for a medication?
• Revenue code 0637 is used for which category?
• What information is included in medication information for PA?
• Dual co-pay refers to
• Which federal agency within the U.S. Department of Health and Human Services is responsible for administering Medicare and Medicaid?
• Which practice is most likely to trigger an audit?
• The timeframe for providing audit data after a request is:
• The timeframe for providing audit data after a request is:
• Which scenario best describes principle care management as defined in the material?
• What are the typical steps in the denial and appeals process for a PA decision?
• What is the billing increment used for drugs and radiological items?
• Which of the following is NOT an incident-to requirement?
• Which of the following situations could trigger an audit?
• Which description best fits the organization that evaluates and accredits different types of healthcare facilities as a not-for-profit entity?
• Which describes a type of prior approval in this context?
• Which of the following is a common third-party rejection reason?
• Which items constitute required insurance information for drug claims?
• APC stands for Ambulatory Payment Classification. The primary purpose is to classify what?
• In a POS plan, what is typically required when using a non-HMO provider?
• Which elements are typically considered in a formulary exception process?
• How are additional patient contact times billed after the initial 15 minutes?
• MAC is defined as
• CMS rules include the concept of Medically Necessary / Usual and Customary. Which option best reflects this?
• Why Accreditation?
• Which statement best defines waste in the context of Medicare program integrity?
• What best describes prior authorization?
• Which plan is described as network-based with a gatekeeper physician coordinating care within the network?
• Which items are required for drug claim submission (drug/script info)?
• What is the correct sequence of the four stages in the audit process timeline?
• ICD codes are used for which purpose?
• What does the acronym FWA stand for in Medicare policy?
• Which of the following describes Average Sales Price (ASP)?
• Which of the following is a role of accreditation agencies?
• Who develops formulary exception policies?
• Which of the following are types of audits?
• In time-based billing for established patients, what does the initial 15 minutes refer to?
• NCQA's founding year was which of the following?
• HOPPS stands for which payment system?
• The Relative Value Unit (RVU) system is used in medical billing for coding to determine payments for which type of items?
• HOPPS is a payment system used for which setting?
• Medicaid is a federal and state assistance program that pays for health care services for people who cannot afford them. Which statement about Medicaid is true?
• Average Manufacturer Price (AMP) is defined as
• AWP is defined as the published average 'cost' of a drug product paid by the pharmacy to the wholesaler.
• What is the fundamental purpose of prior authorization?