CMAA Insurance Verification and Processing 5

Question 1

A patient's plan requires a 'referral' but the patient saw a specialist without one. The claim is denied. Which action best resolves this situation?

Accepted Answer

Contact the primary care physician to obtain a retroactive referral if allowed by the plan

Answer

Some plans allow retroactive referrals; contacting the PCP and the insurer to request one is the correct first step before pursuing other options.

Question 2

What is the purpose of a 'remittance advice' (RA) sent by an insurance payer?

Accepted Answer

To explain how each claim was adjudicated, including payment amounts and denial reasons

Answer

A remittance advice is sent to the provider and details how each submitted claim was processed, including payments made and reasons for any adjustments or denials.

Question 3

A patient's insurance uses a 'usual, customary, and reasonable' (UCR) fee schedule. The provider charges $400, but the UCR for that service is $300. The plan pays 80% of UCR. How much does the insurer pay?

Accepted Answer

$240

Answer

The insurer pays 80% of the UCR ($300), which equals $240; the patient may be responsible for the remaining $60 plus any balance up to the provider's charge if the provider is out of network.

Question 4

A Coordination of Benefits (COB) calculation determines the primary plan pays $150 and the secondary plan's allowed amount would be $180 for the same service. Using the standard COB method, how much does the secondary plan pay?

Accepted Answer

$30, covering the difference between the two allowed amounts

Answer

Under standard COB, the secondary plan pays the difference between its allowed amount and what the primary already paid, so $180 − $150 = $30.

Question 5

Which of the following best describes an 'accumulator' in health insurance?

Accepted Answer

A running total of amounts applied toward the deductible or out-of-pocket maximum during a benefit year

Answer

Accumulators track how much a patient has paid toward cost-sharing thresholds like the deductible and out-of-pocket maximum throughout the plan year.

CMAA - Certified Medical Administrative Assistant Practice Test

CMAA - Certified Medical Administrative Assistant Practice Test

CMAA Insurance Verification and Processing 5