Insurance Verification and Eligibility 9 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 9 flashcards as text
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?
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.
A patient presents for a scheduled MRI. The insurance plan requires advance approval before the service is rendered. This approval is called a:
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.
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?
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.
Which term refers to the individual named on the insurance policy under whose coverage a dependent spouse or child is insured?
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.
A provider is classified as 'in-network' with a patient's insurer. What is the primary financial significance of this status for the patient?
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.
Which of the following best describes 'assignment of benefits' in the context of healthcare access?
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.