CHAA - Certified Healthcare Access Associate Insurance Verification and Eligibility 9 — Questions and Answers
Question 1: When a patient has coverage under two insurance plans, which term describes the process of determining how each plan pays its share of the claim?
- Subrogation
- Coordination of Benefits (Correct answer)
- Assignment of Benefits
- Cross-over Billing
Correct answer: Coordination of Benefits
Coordination of Benefits (COB) is the process used when a patient has dual coverage to determine the order in which each payer is responsible and prevent overpayment beyond 100% of the claim.
Question 2: A patient presents for a scheduled MRI. The insurance plan requires advance approval before the service is rendered. This approval is called a:
- Remittance advice
- Prior authorization (Correct answer)
- Referral waiver
- Concurrent review
Correct answer: Prior authorization
Prior authorization (also called pre-authorization or pre-cert) is the insurer's advance approval that a specific service is medically necessary and covered before it is provided.
Question 3: During eligibility verification, a patient's plan shows a $1,500 deductible with $900 already met. How much deductible remains for the patient to satisfy?
- $900
- $1,500
- $600 (Correct answer)
- $2,400
Correct answer: $600
The remaining deductible is calculated by subtracting the amount already met from the total deductible: $1,500 – $900 = $600. Verifying the accumulated deductible amount prevents unexpected patient balance surprises.
Question 4: Which term refers to the individual named on the insurance policy under whose coverage a dependent spouse or child is insured?
- Guarantor
- Beneficiary
- Subscriber (Correct answer)
- Co-insured
Correct answer: Subscriber
The subscriber (also called the policyholder or insured) is the primary person named on the insurance plan. Dependents such as spouses and children are covered under the subscriber's policy.
Question 5: A provider is classified as 'in-network' with a patient's insurer. What is the primary financial significance of this status for the patient?
- The patient owes no cost-sharing at all
- The provider has agreed to discounted contracted rates, reducing the patient's out-of-pocket costs (Correct answer)
- The claim is automatically approved without prior authorization
- The patient's deductible does not apply to services received
Correct answer: The provider has agreed to discounted contracted rates, reducing the patient's out-of-pocket costs
In-network providers have signed contracts agreeing to negotiated (discounted) rates with the insurer. This lowers the allowed amount and, consequently, the patient's cost-sharing compared to out-of-network care.
Question 6: Which of the following best describes 'assignment of benefits' in the context of healthcare access?
- The insurer assigns a case manager to a patient's account
- The patient authorizes the insurer to pay the provider directly rather than reimbursing the patient (Correct answer)
- The provider assigns billing responsibility to a collection agency
- The patient assigns a power of attorney to a family member
Correct answer: The patient authorizes the insurer to pay the provider directly rather than reimbursing the patient
Assignment of benefits is the patient's written authorization directing the insurance company to send payment directly to the healthcare provider, streamlining the payment process and reducing the patient's out-of-pocket burden at the time of service.
CHAA - Certified Healthcare Access Associate Insurance Verification and Eligibility 9
When a patient has coverage under two insurance plans, which term describes the process of determining how each plan pays its share of the claim?