CMAS Insurance Verification & Prior Authorization 2 — Questions and Answers
Question 1: In a managed care plan, what is a referral?
- A written request from a patient asking to switch primary care physicians
- An authorization from a PCP directing a patient to see a specialist (Correct answer)
- A billing code used to identify the referring provider on a claim
- A document transferring a patient's medical records to another facility
Correct answer: An authorization from a PCP directing a patient to see a specialist
In HMO and some managed care plans, a referral is the PCP's formal direction for the patient to receive specialist care, which is required for insurance to cover the specialist visit.
Question 2: What is Medicare Part B primarily responsible for covering?
- Inpatient hospital stays and skilled nursing facility care
- Prescription drug coverage
- Outpatient medical services, physician visits, and preventive care (Correct answer)
- Long-term custodial nursing home care
Correct answer: Outpatient medical services, physician visits, and preventive care
Medicare Part B covers outpatient services including physician office visits, preventive screenings, durable medical equipment, and outpatient therapy.
Question 3: Which federal program provides health coverage primarily for low-income individuals and is jointly funded by state and federal governments?
- Medicare
- TRICARE
- CHIP
- Medicaid (Correct answer)
Correct answer: Medicaid
Medicaid is a means-tested program jointly funded by federal and state governments that provides health coverage to eligible low-income adults, children, pregnant women, and people with disabilities.
Question 4: When a patient seeks care from a provider outside their HMO network without a referral, what is the MOST likely outcome?
- The insurer will pay the full allowed amount with no penalty
- The claim will be denied or the patient will bear the full cost (Correct answer)
- The provider will automatically become in-network
- Medicare will cover the remaining balance
Correct answer: The claim will be denied or the patient will bear the full cost
HMO plans generally do not cover out-of-network services except in emergencies; the patient is financially responsible for the full cost when proper referral and network requirements are not met.
Question 5: What is the 'birthday rule' used to determine in insurance?
- The date a policy renews each year
- Which parent's plan is primary for a child covered under both parents' policies (Correct answer)
- The age at which a dependent must obtain their own coverage
- The deadline for submitting a prior authorization request
Correct answer: Which parent's plan is primary for a child covered under both parents' policies
The birthday rule states that when a child is covered under both parents' plans, the plan of the parent whose birthday falls earliest in the calendar year is primary.
Question 6: What does 'Assignment of Benefits' mean on a CMS-1500 claim form?
- The patient assigns their deductible responsibility to the provider
- The patient authorizes the insurer to pay the provider directly rather than the patient (Correct answer)
- The provider assigns billing rights to a collection agency
- The insurer assigns the claim to a third-party administrator
Correct answer: The patient authorizes the insurer to pay the provider directly rather than the patient
When a patient signs an assignment of benefits, they authorize their insurance company to send reimbursement payments directly to the healthcare provider instead of to the patient.
Question 7: A medical administrative specialist calls the insurance company to verify benefits and is told the plan has a $30 copay and 80/20 coinsurance after the deductible. What does 80/20 coinsurance mean?
- The patient pays 80% and insurance pays 20% of covered costs after the deductible
- Insurance pays 80% and the patient pays 20% of covered costs after the deductible (Correct answer)
- The patient owes 80% of the deductible and 20% of copays
- Insurance covers 80 procedures per year and 20 emergency visits
Correct answer: Insurance pays 80% and the patient pays 20% of covered costs after the deductible
In an 80/20 coinsurance arrangement, the insurance plan pays 80% of the allowed amount after the deductible is satisfied and the patient is responsible for the remaining 20%.
CMAS Insurance Verification & Prior Authorization 2
In a managed care plan, what is a referral?