CMAA Insurance Verification and Processing 4

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?

Accepted Answer

The patient pays nothing until $3,000 in out-of-network charges is met

Answer

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?

Accepted Answer

The patient must try a lower-cost or first-line treatment before the insurer covers a more expensive option

Answer

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?

Accepted Answer

Review the modifier used and verify it accurately reflects the service rendered

Answer

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?

Accepted Answer

The remaining patient cost-sharing such as coinsurance and copayments not covered by Medicare

Answer

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?

Accepted 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

Answer

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.

CMAA - Certified Medical Administrative Assistant Practice Test

CMAA - Certified Medical Administrative Assistant Practice Test

CMAA Insurance Verification and Processing 4