Payer Types and Coordination of Benefits (COB) 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 Payer Types and Coordination of Benefits (COB) flashcards as text
What is an HMO, and what are its key characteristics for patient access?
Answer: Requires a PCP, referrals for specialists, and in-network providers, making referral and network verification critical
HMOs restrict coverage to in-network providers and typically require PCP referrals.
How does a PPO differ from an HMO for patient access processing?
Answer: PPOs allow in-network and out-of-network providers without referrals, though out-of-network has higher cost-sharing
PPOs offer more flexibility with no PCP requirement or referrals needed.
What is the COB order when a patient has auto insurance liability and commercial health insurance?
Answer: Auto insurance is typically primary for accident-related treatment, with commercial health insurance secondary
For accident-related injuries, auto insurance is typically primary.
What is the difference between participating and non-participating Medicare providers?
Answer: Participating providers accept Medicare's approved amount as full payment; non-participating may charge up to 115% of the fee schedule
Participation status determines billing practices and patient financial responsibility.
A patient presents with a VA identification card. How should patient access handle registration?
Answer: Verify VA eligibility and authorization status, as VA may cover care through the Community Care program
VA-eligible veterans may receive non-VA care through the Community Care program with specific authorization.
What is the 'gender rule' in coordination of benefits?
Answer: An older COB rule where the father's plan was primary for dependents, largely replaced by the birthday rule
The gender rule was replaced by the birthday rule to eliminate gender-based discrimination.