CHAA - Certified Healthcare Access Associate Insurance Verification and Eligibility 9

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?

Accepted Answer

Coordination of Benefits

Answer

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:

Accepted Answer

Prior authorization

Answer

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?

Accepted Answer

$600

Answer

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?

Accepted Answer

Subscriber

Answer

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?

Accepted Answer

The provider has agreed to discounted contracted rates, reducing the patient's out-of-pocket costs

Answer

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.

CHAA - Certified Healthcare Access Associate Practice Test

CHAA - Certified Healthcare Access Associate Practice Test

CHAA - Certified Healthcare Access Associate Insurance Verification and Eligibility 9