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 primary purpose of insurance verification in a medical office?
Answer: To confirm the patient has active coverage and understand their benefits before services are rendered
Insurance verification confirms active coverage, deductibles, copays, and covered services so the office can inform the patient of their financial responsibility before treatment.
Which document does an insurance company send to a patient and provider summarizing how a claim was processed and what the patient owes?
Answer: Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) details the services billed, the amount allowed, what insurance paid, and the patient's remaining responsibility.
What does Coordination of Benefits (COB) determine when a patient has two insurance plans?
Answer: Which insurance plan pays first and how much the secondary plan will contribute
COB rules determine the order in which multiple insurance plans pay to prevent overpayment and ensure combined payments do not exceed 100% of the allowed amount.
Prior authorization (precertification) is MOST commonly required for which type of service?
Answer: Elective surgeries and specialty referrals
Insurers require prior authorization for non-urgent or elective procedures and specialist services to verify medical necessity before approving coverage.
When verifying a patient's insurance, which of the following pieces of information is MOST critical to collect?
Answer: The group number, member ID, effective date, and copay/deductible amounts
Group number, member ID, effective/termination dates, and cost-sharing details (copay, deductible, coinsurance) are essential to determine active coverage and patient liability.
A patient's insurance plan has a $1,500 annual deductible and they have met $900 so far. How much of the deductible remains before insurance begins paying?
Answer: $600
$1,500 total deductible minus $900 already met equals $600 remaining before the insurer begins covering costs.
What is a formulary in the context of health insurance?
Answer: A list of prescription drugs covered by an insurance plan
A formulary is the insurer's approved list of prescription medications, often organized into tiers that determine the patient's copay for each drug.