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Section 1
AAPC CPB blueprint — managed care payer structures
Preview
Preview: Types of insurance
Preview includes- 4 of 5 lesson topics
- 1 overview segment
- 3 core concepts
- 2 exam tips
Lesson Topics
- managed care payer structures
- Core rules and definitions
- Billing workflow/application
- Common exam traps
Overview
Managed care questions test how network design, referrals, authorization, and payment arrangements affect front-end billing and patient responsibility.
Core Concepts
- HMO plans generally emphasize network use and may require PCP/referral pathways; always verify the member’s actual benefit design.
- PPO plans generally allow broader provider choice, with different in-network and out-of-network cost sharing.
- POS plans combine managed-care features and may allow out-of-network care at higher patient cost.
Exam Tips
- For scenario questions, identify the plan type, network status, referral/authorization requirement, and patient cost-sharing before choosing an action.
- Never assume a referral or authorization guarantees payment.
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Section 2
AAPC CPB blueprint — commercial health insurance
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Section 3
AAPC CPB blueprint — Medicare
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Section 4
AAPC CPB blueprint — Medigap
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Section 5
AAPC CPB blueprint — Medicaid
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Section 6
AAPC CPB blueprint — Blue Cross Blue Shield
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Section 7
AAPC CPB blueprint — TRICARE/CHAMPUS
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Section 8
AAPC CPB blueprint — workers compensation
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Section 9
AAPC CPB blueprint — automobile, liability and other third-party payers
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Section 10
AAPC CPB blueprint — accountable care organizations
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Section 11
AAPC CPB blueprint — NCCI edits
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Section 12
AAPC CPB blueprint — LCDs and NCDs
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Section 13
AAPC CPB blueprint — incident-to billing
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Section 14
AAPC CPB blueprint — global surgical package
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Section 15
AAPC CPB blueprint — unbundling
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Section 16
AAPC CPB blueprint — CMS-1500 completion
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Section 17
AAPC CPB blueprint — UB-04 completion
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Section 18
AAPC CPB blueprint — payer payment policies
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Section 19
AAPC CPB blueprint — HIPAA privacy
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Section 20
AAPC CPB blueprint — HIPAA security
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Section 21
AAPC CPB blueprint — billing compliance
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Section 22
AAPC CPB blueprint — medical-record retention
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Section 23
AAPC CPB blueprint — financial policies
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Section 24
AAPC CPB blueprint — fraud and abuse
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Section 25
AAPC CPB blueprint — RBRVS and fee schedules
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Section 26
AAPC CPB blueprint — payer and patient refunds
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Section 27
AAPC CPB blueprint — provider credentialing and enrollment
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Section 28
AAPC CPB blueprint — accounts receivable
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Section 29
AAPC CPB blueprint — patient collections
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Section 30
AAPC CPB blueprint — medical necessity and preauthorization
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Section 31
AAPC CPB blueprint — remittance advice and payment posting
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Section 32
AAPC CPB blueprint — fair debt, agencies and bankruptcy
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Section 33
AAPC CPB blueprint — appeals
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Section 34
AAPC CPB blueprint — denials
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Section 35
AAPC CPB blueprint — claims tracking and follow-up
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Section 36
AAPC CPB blueprint — timely filing
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Section 37
AAPC CPB blueprint — demographics and charge capture
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Section 38
AAPC CPB blueprint — balance billing and beneficiary liability
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Section 39
AAPC CPB blueprint — electronic claims and clean claims
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Section 40
AAPC CPB blueprint — auditing and records
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Section 41
AAPC CPB blueprint — telephone courtesy and privacy
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Section 42
AAPC CPB blueprint — corrected and replacement claims
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Section 43
AAPC CPB blueprint — ICD-10-CM
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Section 44
AAPC CPB blueprint — CPT and modifiers
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Section 45
AAPC CPB blueprint — HCPCS Level II and POS
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Section 46
AAPC CPB blueprint — CMS-1500 case analysis
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Section 47
AAPC CPB blueprint — payment policy case analysis
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Section 48
AAPC CPB blueprint — LCD/NCD case analysis
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Section 49
AAPC CPB blueprint — appeal letter case analysis
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Section 50
AAPC CPB blueprint — preauthorization case analysis
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Section 51
AAPC CPB blueprint — accounts receivable report case analysis
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Section 52
AAPC CPB blueprint — claims follow-up report case analysis
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