CHAA Insurance Verification and Eligibility — Questions and Answers
Question 1: What is the primary purpose of insurance eligibility verification?
- To determine the patient's medical diagnosis
- To confirm that a patient has active insurance coverage and to understand their benefits before services are rendered (Correct answer)
- To collect the patient's copayment
- To schedule follow-up appointments
Correct answer: To confirm that a patient has active insurance coverage and to understand their benefits before services are rendered
Insurance eligibility verification confirms that a patient has active coverage under their stated insurance plan and provides details about their benefits, including copays, deductibles, and coverage limitations. Performing this step before services are rendered prevents many claim denials. It is one of the most impactful front-end revenue cycle activities.
Question 2: Which of the following is NOT typically verified during insurance eligibility checks?
- Active coverage status
- Patient's blood type (Correct answer)
- Deductible and copay amounts
- In-network provider status
Correct answer: Patient's blood type
Blood type is clinical information and is not part of insurance eligibility verification. The verification process confirms active coverage, plan type, deductible status, copay and coinsurance amounts, out-of-pocket maximum status, and whether the provider is in-network. Clinical data is managed separately through the medical record.
Question 3: What is a '270' transaction in the context of eligibility verification?
- A patient billing statement
- An electronic health care eligibility inquiry sent to a payer (Correct answer)
- A claim submission form
- A referral authorization request
Correct answer: An electronic health care eligibility inquiry sent to a payer
The 270 transaction is the HIPAA-mandated electronic standard for submitting eligibility inquiries to insurance companies. It contains patient demographic and plan information and is sent to the payer to request verification of coverage. The payer responds with a 271 transaction containing the eligibility details.
Question 4: What information is returned in a '271' eligibility response?
- The patient's complete medical history
- Coverage status, plan details, deductible information, copay amounts, and benefit specifics (Correct answer)
- The provider's tax identification number
- The patient's prescription history
Correct answer: Coverage status, plan details, deductible information, copay amounts, and benefit specifics
The 271 response contains the patient's coverage status, plan details, effective dates, deductible amounts and accumulations, copay requirements, coinsurance percentages, out-of-pocket maximum status, and any limitations or exclusions. This comprehensive information enables accurate patient estimates and proper claim submission.
Question 5: When should insurance eligibility verification ideally occur?
- After the patient has been discharged
- At least 48-72 hours before the scheduled appointment and again at the time of service (Correct answer)
- Only when the patient requests it
- After the claim has been submitted
Correct answer: At least 48-72 hours before the scheduled appointment and again at the time of service
Best practice is to verify eligibility at least 48-72 hours before the appointment and again at the time of service. The advance verification allows time to resolve any issues, obtain authorizations, or contact the patient about potential financial responsibility. Reverification at check-in catches any last-minute coverage changes.
Question 6: What is the difference between 'eligibility' and 'benefits verification'?
- They are exactly the same thing
- Eligibility confirms active coverage, while benefits verification determines specific plan details like deductibles, copays, and covered services (Correct answer)
- Eligibility is done by the payer, benefits by the provider
- Benefits verification is only needed for surgical patients
Correct answer: Eligibility confirms active coverage, while benefits verification determines specific plan details like deductibles, copays, and covered services
Eligibility verification confirms that a patient has active insurance coverage on a given date. Benefits verification goes deeper, identifying the specific plan details such as deductible amounts, copay requirements, coinsurance rates, coverage limitations, and authorization requirements. Both are important but serve different purposes in the pre-service process.
CHAA Insurance Verification and Eligibility
What is the primary purpose of insurance eligibility verification?