CHAA Payer Types and Coordination of Benefits (COB) 3

Question 1

What is an HMO, and what are its key characteristics for patient access?

Accepted Answer

Requires a PCP, referrals for specialists, and in-network providers, making referral and network verification critical

Answer

HMOs restrict coverage to in-network providers and typically require PCP referrals.

Question 2

How does a PPO differ from an HMO for patient access processing?

Accepted Answer

PPOs allow in-network and out-of-network providers without referrals, though out-of-network has higher cost-sharing

Answer

PPOs offer more flexibility with no PCP requirement or referrals needed.

Question 3

What is the COB order when a patient has auto insurance liability and commercial health insurance?

Accepted Answer

Auto insurance is typically primary for accident-related treatment, with commercial health insurance secondary

Answer

For accident-related injuries, auto insurance is typically primary.

Question 4

What is the difference between participating and non-participating Medicare providers?

Accepted Answer

Participating providers accept Medicare's approved amount as full payment; non-participating may charge up to 115% of the fee schedule

Answer

Participation status determines billing practices and patient financial responsibility.

Question 5

A patient presents with a VA identification card. How should patient access handle registration?

Accepted Answer

Verify VA eligibility and authorization status, as VA may cover care through the Community Care program

Answer

VA-eligible veterans may receive non-VA care through the Community Care program with specific authorization.

CHAA - Certified Healthcare Access Associate Practice Test