CMAA Insurance Verification and Processing 4 — Questions and Answers
Question 1: A patient's insurance card shows 'OON deductible: $3,000' and 'IN deductible: $500'. The patient wants to see an out-of-network specialist. What does the OON deductible mean?
- The patient pays nothing until $3,000 in out-of-network charges is met (Correct answer)
- The patient owes $3,000 per visit to out-of-network providers
- The insurance pays $3,000 toward out-of-network services annually
- The out-of-network deductible is waived after $3,000 in claims
Correct answer: The patient pays nothing until $3,000 in out-of-network charges is met
The out-of-network (OON) deductible is the amount the patient must pay out of pocket for out-of-network services before the insurance begins sharing costs.
Question 2: When verifying benefits, you learn a procedure requires 'step therapy.' What does this mean?
- The patient must try a lower-cost or first-line treatment before the insurer covers a more expensive option (Correct answer)
- The procedure requires multiple steps and multiple authorizations
- The provider must bill in sequential steps over several visits
- The patient must step through a referral chain before authorization is granted
Correct answer: The patient must try a lower-cost or first-line treatment before the insurer covers a more expensive option
Step therapy requires patients to try and fail on preferred (usually less expensive) treatments before the insurer will cover a more advanced or costly option.
Question 3: A claim is returned with denial code CO-4. This code means the procedure code is inconsistent with the modifier. What is the most appropriate first action?
- Review the modifier used and verify it accurately reflects the service rendered (Correct answer)
- Resubmit the claim with no modifier
- Appeal the denial without making changes
- Bill the patient for the full amount
Correct answer: Review the modifier used and verify it accurately reflects the service rendered
CO-4 denials indicate a mismatch between the procedure code and the modifier, so the biller should review the documentation and correct the modifier before resubmitting.
Question 4: A patient presents with both Medicare Part B and a Medigap (supplemental) plan. After Medicare processes the claim, what does Medigap typically cover?
- The remaining patient cost-sharing such as coinsurance and copayments not covered by Medicare (Correct answer)
- The entire bill if Medicare denies the claim
- Only prescription drug costs not covered by Medicare
- The Medicare Part B premium on behalf of the patient
Correct answer: The remaining patient cost-sharing such as coinsurance and copayments not covered by Medicare
Medigap plans are designed to cover cost-sharing gaps left by Medicare, such as coinsurance, copayments, and sometimes deductibles.
Question 5: You are verifying insurance for a patient who has both a primary and secondary insurer. The secondary insurer uses the 'non-duplication' provision. What does this mean?
- The secondary plan will not pay if the primary plan paid at least as much as the secondary plan would have paid on its own (Correct answer)
- The secondary plan duplicates the primary plan's payment exactly
- The patient cannot use two insurers for the same service
- The secondary insurer pays first for preventive services
Correct answer: The secondary plan will not pay if the primary plan paid at least as much as the secondary plan would have paid on its own
A non-duplication provision means the secondary plan pays nothing if the primary plan's payment equals or exceeds what the secondary plan would have paid as the primary payer.
Question 6: A provider's contract with an insurer includes a 'clean claim' submission deadline of 90 days. A claim for a service on March 1 is submitted on June 15. What is the likely outcome?
- The claim may be denied for timely filing because it was submitted after the 90-day deadline (Correct answer)
- The claim will be paid because it is within the calendar year
- The insurer must accept the claim because a clean claim has no errors
- The claim will be placed on hold until the next billing cycle
Correct answer: The claim may be denied for timely filing because it was submitted after the 90-day deadline
A timely filing denial occurs when a claim is submitted after the contractually agreed deadline, which in this case was 90 days from March 1 (June 1).
Question 7: Which document serves as the primary source of truth when resolving a dispute about what services are covered under a patient's health plan?
- The Summary Plan Description (SPD) or Evidence of Coverage (EOC) document (Correct answer)
- The patient's insurance card
- The provider's fee schedule
- The Explanation of Benefits (EOB) from a prior claim
Correct answer: The Summary Plan Description (SPD) or Evidence of Coverage (EOC) document
The Summary Plan Description or Evidence of Coverage is the official legal document detailing all covered benefits, exclusions, and plan rules.
CMAA Insurance Verification and Processing 4
A patient's insurance card shows 'OON deductible: $3,000' and 'IN deductible: $500'.
The patient wants to see an out-of-network specialist.
What does the OON deductible mean?