CMAS Insurance Verification & Prior Authorization

Question 1

What is the primary purpose of insurance verification in a medical office?

Accepted Answer

To confirm the patient has active coverage and understand their benefits before services are rendered

Answer

To determine the patient's diagnosis before the visit

Answer

To collect the patient's full premium payment upfront

Answer

To notify the insurance company of a potential lawsuit

Question 2

Which document does an insurance company send to a patient and provider summarizing how a claim was processed and what the patient owes?

Accepted Answer

Explanation of Benefits (EOB)

Answer

Superbill

Answer

Remittance Advice (RA)

Answer

Certificate of Coverage (COC)

Question 3

What does Coordination of Benefits (COB) determine when a patient has two insurance plans?

Accepted Answer

Which insurance plan pays first and how much the secondary plan will contribute

Answer

Which provider is the patient's primary care physician

Answer

Whether the patient qualifies for Medicaid

Answer

The maximum out-of-pocket limit for the policy year

Question 4

Prior authorization (precertification) is MOST commonly required for which type of service?

Accepted Answer

Elective surgeries and specialty referrals

Answer

Routine annual physical examinations

Answer

Emergency room visits for life-threatening conditions

Answer

Standard laboratory blood draws ordered by a PCP

Question 5

When verifying a patient's insurance, which of the following pieces of information is MOST critical to collect?

Accepted Answer

The group number, member ID, effective date, and copay/deductible amounts

Answer

The patient's employer's annual revenue

Answer

The name of the insurance agent who sold the policy

Answer

The patient's prior year tax return information

Question 6

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?

Accepted Answer

$600

Answer

$900

Answer

$1,500

Answer

$2,400

Question 7

What is a formulary in the context of health insurance?

Accepted Answer

A list of prescription drugs covered by an insurance plan

Answer

A standardized patient intake form

Answer

A government-mandated fee schedule for procedures

Answer

A document authorizing a patient to see a specialist