CHAA - Certified Healthcare Access Associate Insurance Verification and Eligibility 2 — Questions and Answers
Question 1: When a patient has both a primary and secondary insurance plan, which process determines which insurer pays first?
- Subrogation
- Coordination of Benefits (COB) (Correct answer)
- Retroactive eligibility
- Assignment of Benefits
Correct answer: Coordination of Benefits (COB)
Coordination of Benefits (COB) is the process used when a patient has multiple insurance plans to determine the order in which each plan pays, preventing duplicate reimbursement exceeding 100% of the claim.
Question 2: A patient's insurance card shows an effective date of 08/01/2026 but today is 07/23/2026. What should the access associate do?
- Register the patient and bill the insurer anyway
- Inform the patient their coverage has not yet begun and discuss payment options (Correct answer)
- Contact the employer to backdate the policy
- Assume the date is a misprint and proceed normally
Correct answer: Inform the patient their coverage has not yet begun and discuss payment options
Coverage cannot be billed before the effective date. The associate must inform the patient their policy is not yet active and explore alternatives such as self-pay, financial assistance, or rescheduling.
Question 3: Which term describes the fixed dollar amount a patient must pay out-of-pocket for a covered service before insurance begins to pay?
- Copayment
- Out-of-pocket maximum
- Deductible (Correct answer)
- Coinsurance
Correct answer: Deductible
A deductible is the set amount the insured must pay each benefit period before the insurance plan starts covering costs. Copayments are fixed per-visit fees, and coinsurance is a percentage share paid after the deductible.
Question 4: During eligibility verification, a healthcare access associate confirms a patient is 'in-network.' What does this mean for the patient?
- The patient owes no cost-sharing for any services
- The provider has a contracted rate with the insurer, typically resulting in lower patient cost-sharing (Correct answer)
- The patient's claim will be paid at 100% with no deductible
- The patient does not need a referral for specialist visits
Correct answer: The provider has a contracted rate with the insurer, typically resulting in lower patient cost-sharing
In-network status means the provider has negotiated contracted rates with the insurer. Patients generally pay less out-of-pocket than they would for out-of-network services, but cost-sharing like copays and deductibles still apply.
Question 5: Which of the following situations would most likely require a pre-authorization before the service is rendered?
- An annual wellness visit with the patient's primary care physician
- An elective MRI ordered by a specialist (Correct answer)
- A routine blood draw ordered during an office visit
- An emergency room visit following an accident
Correct answer: An elective MRI ordered by a specialist
Elective diagnostic imaging such as MRIs frequently requires prior authorization from the insurer to confirm medical necessity before the service is performed. Emergency services are generally exempt from pre-authorization requirements.
Question 6: A patient's eligibility response shows their plan type as 'HMO.' Which of the following access considerations is MOST relevant?
- The patient may self-refer to any specialist without restriction
- The patient likely requires a referral from a primary care physician to see a specialist (Correct answer)
- The patient's deductible resets every visit
- The patient has no out-of-pocket maximum under this plan type
Correct answer: The patient likely requires a referral from a primary care physician to see a specialist
Health Maintenance Organization (HMO) plans typically require members to select a primary care physician (PCP) and obtain a referral from that PCP before seeing a specialist. Failure to follow this process may result in claim denial.
CHAA - Certified Healthcare Access Associate Insurance Verification and Eligibility 2
When a patient has both a primary and secondary insurance plan, which process determines which insurer pays first?