CMAS Insurance Verification & Prior Authorization 2

Question 1

In a managed care plan, what is a referral?

Accepted Answer

An authorization from a PCP directing a patient to see a specialist

Answer

A written request from a patient asking to switch primary care physicians

Answer

A billing code used to identify the referring provider on a claim

Answer

A document transferring a patient's medical records to another facility

Question 2

What is Medicare Part B primarily responsible for covering?

Accepted Answer

Outpatient medical services, physician visits, and preventive care

Answer

Inpatient hospital stays and skilled nursing facility care

Answer

Prescription drug coverage

Answer

Long-term custodial nursing home care

Question 3

Which federal program provides health coverage primarily for low-income individuals and is jointly funded by state and federal governments?

Accepted Answer

Medicaid

Answer

Medicare

Answer

TRICARE

Answer

CHIP

Question 4

When a patient seeks care from a provider outside their HMO network without a referral, what is the MOST likely outcome?

Accepted Answer

The claim will be denied or the patient will bear the full cost

Answer

The insurer will pay the full allowed amount with no penalty

Answer

The provider will automatically become in-network

Answer

Medicare will cover the remaining balance

Question 5

What is the 'birthday rule' used to determine in insurance?

Accepted Answer

Which parent's plan is primary for a child covered under both parents' policies

Answer

The date a policy renews each year

Answer

The age at which a dependent must obtain their own coverage

Answer

The deadline for submitting a prior authorization request

Question 6

What does 'Assignment of Benefits' mean on a CMS-1500 claim form?

Accepted Answer

The patient authorizes the insurer to pay the provider directly rather than the patient

Answer

The patient assigns their deductible responsibility to the provider

Answer

The provider assigns billing rights to a collection agency

Answer

The insurer assigns the claim to a third-party administrator

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?

Accepted Answer

Insurance pays 80% and the patient pays 20% of covered costs after the deductible

Answer

The patient pays 80% and insurance pays 20% of covered costs after the deductible

Answer

The patient owes 80% of the deductible and 20% of copays

Answer

Insurance covers 80 procedures per year and 20 emergency visits