Insurance Verification and Processing Flashcards
6 cards from real CMAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Insurance Verification and Processing flashcards as text
What is the difference between an HMO and a PPO?
Answer: HMOs require referrals and in-network use; PPOs allow out-of-network at higher cost
HMOs require in-network providers and referrals. PPOs allow out-of-network care at higher cost without referrals.
Which standard electronic transaction is used for insurance eligibility verification?
Answer: ANSI 270/271
The 270/271 transaction set handles eligibility inquiries (270) and responses (271).
A card shows 'Coinsurance: 80/20 after deductible.' What does this mean?
Answer: Insurance pays 80%, patient pays 20% after deductible
80/20 coinsurance means after the deductible is met, insurance pays 80% and the patient pays 20%.
What should a CMAA do if verification reveals the patient's coverage is terminated?
Answer: Inform the patient and discuss self-pay options or payment plans
Inform the patient, verify accuracy, and present alternatives such as self-pay rates or payment plans.
What is an EOB used for in the insurance processing workflow?
Answer: Reconcile insurance payments and identify patient responsibility
The EOB reconciles insurance payments by comparing billed amounts, allowed amounts, payments, and patient responsibility.
Which plan allows any provider without restrictions but reimburses more for in-network?
Answer: PPO
PPO plans allow any provider without referrals but provide higher reimbursement for in-network providers.