Insurance Verification & Prior Authorization Flashcards
7 cards from real CMAS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Insurance Verification & Prior Authorization flashcards as text
What is the National Provider Identifier (NPI) and why is it required on insurance claims?
Answer: A unique 10-digit identifier assigned to healthcare providers required by HIPAA for electronic transactions
The NPI is a HIPAA-mandated unique 10-digit number that identifies healthcare providers in standard electronic transactions and must appear on all insurance claims.
What is the difference between a copayment and coinsurance?
Answer: A copayment is a flat dollar amount paid at the time of service; coinsurance is a percentage of costs shared after the deductible
A copayment is a fixed dollar amount (e.g., $25) paid at each visit, while coinsurance is a percentage (e.g., 20%) of the allowed amount the patient owes after the deductible has been met.
A prior authorization is submitted for an MRI and the insurer denies it as 'not medically necessary.' What should the medical administrative specialist do first?
Answer: File an appeal with supporting clinical documentation from the ordering provider
When a prior authorization is denied for lack of medical necessity, the next step is to appeal the decision by submitting additional clinical documentation that supports the medical necessity of the requested service.
What is a Certificate of Medical Necessity (CMN) primarily used for?
Answer: Justifying coverage for durable medical equipment (DME) under Medicare
A CMN is a form completed by the ordering physician to document that durable medical equipment (such as a wheelchair or oxygen) is medically necessary for the patient, which is required by Medicare for DME coverage.
When verifying insurance for a new patient, the representative states the patient's coverage is 'active but pending.' What should the administrative specialist do?
Answer: Document the pending status, collect the patient's cost-sharing upfront, and recheck eligibility on the date of service
When coverage is pending, the safest practice is to note the status, collect expected cost-sharing amounts, and re-verify on the date of service to confirm the coverage is fully active before billing.
Which of the following BEST describes the purpose of a remittance advice (RA) sent from an insurer to a provider?
Answer: It is a payment explanation detailing how claims were adjudicated and how much was paid or denied
A remittance advice is sent by the payer to the provider and itemizes each claim adjudicated, showing allowed amounts, adjustments, payments, and denial reasons — it is used to post payments and work denials.
What is an out-of-pocket maximum in a health insurance plan?
Answer: The cap on total cost-sharing a patient pays in a plan year, after which insurance covers 100% of covered services
The out-of-pocket maximum is the most a patient will pay in deductibles, copayments, and coinsurance in a plan year; once reached, the insurer pays 100% of covered in-network services for the remainder of the year.