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

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?

Accepted Answer

Outpatient medical services, physician visits, and preventive care

Answer

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?

Accepted Answer

Medicaid

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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.

(CMAS) Certified Medical Administrative Specialist Practice Test

(CMAS) Certified Medical Administrative Specialist Practice Test

CMAS Insurance Verification & Prior Authorization 2