Insurance Eligibility Verification Flashcards
6 cards from real CBCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Insurance Eligibility Verification flashcards as text
What is the difference between a 'subscriber' and a 'dependent' in health insurance?
Answer: A subscriber is the individual who enrolls in and is primarily covered by the insurance policy; a dependent is a family member (spouse, child) covered under the subscriber's plan
The subscriber (or policyholder) is the person who enrolled in the health plan, often through an employer. Dependents are family members who receive coverage under the subscriber's policy.
Why is it important to verify insurance eligibility for established patients, not just new patients?
Answer: Insurance coverage can change due to job changes, open enrollment, aging off a parent's plan, or COBRA expiration — verifying at each visit prevents claim denials
Insurance coverage is not static — it changes frequently due to employment changes, life events, plan changes during open enrollment, and coverage terminations. Verifying at each encounter prevents billing errors and denials.
What is an open enrollment period in the context of insurance coverage?
Answer: A designated time period when employees can enroll in, change, or cancel employer-sponsored health insurance coverage
Open enrollment is the annual window during which eligible individuals can select or change their health insurance plan. Outside of open enrollment, changes are generally only allowed for qualifying life events.
What is a Certificate of Creditable Coverage and why is it relevant to billing?
Answer: A document from a prior health plan confirming the length of previous creditable coverage, which can reduce pre-existing condition waiting periods under some plans
A Certificate of Creditable Coverage documents a patient's prior continuous health insurance coverage. Under pre-ACA rules, it could reduce waiting periods for pre-existing condition exclusions under new employer group plans.
What is a 'participating provider' vs. 'non-participating provider' in insurance networks?
Answer: Participating providers have signed contracts with the insurance plan and accept negotiated rates; non-participating providers have no contract and may charge higher rates with different patient liability
Participating (in-network) providers have contracts with the insurance plan and agree to accept the negotiated allowed amount. Non-participating (out-of-network) providers have no contract, and patients typically face higher out-of-pocket costs.
What is 'retroactive termination' of insurance coverage and how should a biller handle it?
Answer: When an insurance company cancels coverage effective on a past date, making previously submitted claims subject to recoupment or denial
Retroactive termination occurs when coverage is ended with an effective date in the past. This can affect claims already submitted and paid, potentially requiring refunds to the payer and re-billing the patient or other coverage.