CMAA Insurance Verification and Processing 3

Question 1

What is the difference between an HMO and a PPO?

Accepted Answer

HMOs require referrals and in-network use; PPOs allow out-of-network at higher cost

Answer

HMOs have higher premiums

Answer

PPOs require a PCP while HMOs do not

Answer

No meaningful difference

Question 2

Which standard electronic transaction is used for insurance eligibility verification?

Accepted Answer

ANSI 270/271

Answer

ANSI 837P

Answer

ANSI 835

Answer

ANSI 276/277

Question 3

A card shows 'Coinsurance: 80/20 after deductible.' What does this mean?

Accepted Answer

Insurance pays 80%, patient pays 20% after deductible

Answer

Patient pays 80%, insurance pays 20%

Answer

Patient pays $80, insurance pays $20

Answer

Patient has met 80% of deductible

Question 4

What should a CMAA do if verification reveals the patient's coverage is terminated?

Accepted Answer

Inform the patient and discuss self-pay options or payment plans

Answer

Refuse to see the patient

Answer

Bill the insurance anyway

Answer

Contact insurance to reinstate coverage

Question 5

What is an EOB used for in the insurance processing workflow?

Accepted Answer

Reconcile insurance payments and identify patient responsibility

Answer

Verify eligibility before appointments

Answer

Obtain prior authorization

Answer

Submit initial claims

Question 6

Which plan allows any provider without restrictions but reimburses more for in-network?

Accepted Answer

PPO

Answer

HMO

Answer

EPO

Answer

POS