Insurance Verification and Eligibility 2 Flashcards
6 cards from real CHAA 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 Verification and Eligibility 2 flashcards as text
When a patient has both a primary and secondary insurance plan, which process determines which insurer pays first?
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.
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?
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.
Which term describes the fixed dollar amount a patient must pay out-of-pocket for a covered service before insurance begins to pay?
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.
During eligibility verification, a healthcare access associate confirms a patient is 'in-network.' What does this mean for the patient?
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.
Which of the following situations would most likely require a pre-authorization before the service is rendered?
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.
A patient's eligibility response shows their plan type as 'HMO.' Which of the following access considerations is MOST relevant?
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.