Insurance Verification and Processing Flashcards

A new patient provides their insurance card at check-in. Which of the following is the MOST critical first step for the CMAA to take to prevent claim denials?

Answer: Verify insurance eligibility and benefits.

Verifying insurance eligibility and benefits is the most critical initial step. This process confirms that the patient's coverage is active on the date of service and clarifies what services are covered, preventing future claim denials and ensuring the patient understands their financial responsibility.

A patient is covered by two insurance plans: one through their own employer and another as a dependent on their spouse's plan. The process of determining which plan is primary and which is secondary is known as:

Answer: Coordination of Benefits (COB)

Coordination of Benefits (COB) is the process used to determine the order of payment when a patient is covered by more than one health insurance plan. This ensures that payments do not exceed the total charge for the service.

A patient's insurance plan requires them to pay a fixed amount of $30 for each office visit. This type of payment is called a(n):

Answer: Copayment

A copayment (or copay) is a fixed, flat fee that a patient pays for a covered healthcare service at the time of the visit.

A CMAA is reviewing a document from a payer that details the payment, adjustments, and any denials for a batch of recently submitted claims. This document is sent to the provider's office and is called a(n):

Answer: Remittance Advice (RA)

A Remittance Advice (RA), often sent electronically (ERA), is a document provided by an insurance payer to a healthcare provider that explains the payment and any adjustments made to claims. An Explanation of Benefits (EOB) contains similar information but is sent to the patient.

A provider recommends a specific surgical procedure for a patient. The patient's insurance policy requires the medical office to obtain approval from the insurer before the procedure can be performed to ensure it will be covered. This process is called:

Answer: Preauthorization

Preauthorization, also known as prior authorization, is the process of getting approval from the insurance company before a specific service or procedure is delivered to a patient to ensure it is considered medically necessary and will be covered.

Which of the following describes the patient's financial responsibility that is a percentage of the allowed amount for a service, which they must pay after their deductible has been met?

Answer: Coinsurance

Coinsurance is the percentage of costs of a covered health care service you pay after you've paid your deductible. For example, with an 80/20 coinsurance plan, the insurance company pays 80% and the patient is responsible for 20%.