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 require in-network providers and referrals. PPOs allow out-of-network care at higher cost without referrals.

Question 2

Which standard electronic transaction is used for insurance eligibility verification?

Accepted Answer

ANSI 270/271

Answer

The 270/271 transaction set handles eligibility inquiries (270) and responses (271).

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

80/20 coinsurance means after the deductible is met, insurance pays 80% and the patient pays 20%.

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

Inform the patient, verify accuracy, and present alternatives such as self-pay rates or payment plans.

Question 5

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

Accepted Answer

Reconcile insurance payments and identify patient responsibility

Answer

The EOB reconciles insurance payments by comparing billed amounts, allowed amounts, payments, and patient responsibility.

CMAA - Certified Medical Administrative Assistant Practice Test