CBCS Insurance Eligibility Verification 2

Question 1

What is the 270/271 transaction in healthcare eligibility verification?

Accepted Answer

The HIPAA standard electronic transaction for eligibility and benefit inquiry (270) and response (271)

Answer

The 270 is the electronic eligibility inquiry sent to payers; the 271 is the response containing the patient's coverage details, benefits, and cost-sharing information.

Question 2

What should be verified during insurance eligibility verification before an appointment?

Accepted Answer

Active coverage, effective dates, deductible/coinsurance/copay amounts, referral requirements, network status of provider, and coverage for the specific services planned

Answer

Complete eligibility verification encompasses active coverage status, benefit details (deductible, copay, coinsurance), out-of-pocket maximum, referral/authorization requirements, and whether the planned services are covered.

Question 3

What does 'coordination of benefits (COB) information' need to be confirmed during eligibility verification for a patient with two insurance plans?

Accepted Answer

Which plan is primary (pays first), which is secondary, and whether the plans coordinate to prevent duplicate payment

Answer

COB verification confirms the payment order — which plan is primary and which is secondary — and ensures proper billing sequence to comply with both plans' requirements and maximize claim payment.

Question 4

What is the Medicare Secondary Payer (MSP) rule?

Accepted Answer

Certain situations require Medicare to pay as secondary to another payer, such as employer group health plans for active workers, workers' compensation, or auto accident liability insurance

Answer

MSP rules specify situations where Medicare must pay after another insurer — including active worker employer group health plans, workers' compensation, FECA, auto/liability insurance, and ESRD group health plans during a coordination period.

Question 5

What is the purpose of a voice authorization in insurance verification?

Accepted Answer

To verify coverage and obtain an authorization number from the payer over the phone when electronic verification is unavailable or inconclusive

Answer

Voice authorization involves calling the payer's provider services line to verify benefits and obtain a reference or authorization number when electronic verification doesn't provide sufficient detail or when real-time approval is needed.

(CBCS) Certified Billing and Coding Specialist Practice Test

(CBCS) Certified Billing and Coding Specialist Practice Test

CBCS Insurance Eligibility Verification 2