CHAA Insurance Verification and Eligibility Flashcards

What is 'medical necessity' and how does it affect coverage?

Answer: The determination that a healthcare service is clinically appropriate and needed for the patient's condition, which is required for insurance coverage

Medical necessity is the determination that a healthcare service is clinically appropriate, needed, and consistent with evidence-based standards for the patient's diagnosis or condition. Most insurance plans only cover services deemed medically necessary. Services that fail medical necessity review may be denied, making it important to understand and communicate this requirement during the verification process.

What is a 'waiting period' in insurance eligibility?

Answer: The period between an employee's hire date and when their insurance coverage becomes effective

A waiting period is the time between when a new employee is hired and when their employer-sponsored health insurance coverage begins. Under the ACA, waiting periods cannot exceed 90 days. During this period, a new employee and their dependents do not have coverage through that employer and may need COBRA, marketplace, or other coverage.

What is 'third-party liability' in insurance verification?

Answer: A situation where another party, such as an auto insurer or workers' compensation, may be responsible for paying a patient's medical bills

Third-party liability exists when another party may be financially responsible for a patient's medical expenses, such as an auto insurance company for car accident injuries or workers' compensation for job-related injuries. Identifying third-party liability during registration ensures claims are submitted to the correct payer. Health insurance may be secondary to third-party liability coverage.

What is 'auto-verification' or 'batch eligibility' processing?

Answer: Automated electronic verification of insurance eligibility for a batch of scheduled patients before their appointments

Batch eligibility processing automatically verifies insurance eligibility for all patients scheduled for upcoming appointments, typically running overnight or at set intervals. This proactive approach identifies coverage issues days before the appointment, allowing staff to resolve problems in advance. It is more efficient than individually checking each patient at the time of registration.

What is an 'insurance discovery' tool?

Answer: Software that searches payer databases to identify active insurance coverage for patients who present as self-pay or uninsured

Insurance discovery tools search multiple payer databases using patient demographic information to identify any active insurance coverage the patient may have but did not report. These tools help convert self-pay accounts to insured accounts, recovering significant revenue. They are especially valuable for emergency department patients who may not have their insurance information available.

What is the purpose of verifying 'pre-certification requirements' during eligibility checks?

Answer: To identify which planned services require insurance approval before they can be performed to prevent authorization-related denials

Verifying pre-certification requirements during eligibility checks identifies which planned services, procedures, or admissions require prior approval from the insurance company before they can be performed. This proactive step allows sufficient time to obtain authorizations and prevents denials related to missing pre-certifications, which are among the most common and costly denial reasons.