CMAS Insurance Verification & Prior Authorization 3

Question 1

What is the National Provider Identifier (NPI) and why is it required on insurance claims?

Accepted Answer

A unique 10-digit identifier assigned to healthcare providers required by HIPAA for electronic transactions

Answer

A state license number that identifies a provider within one state

Answer

A billing code that replaces CPT codes on Medicare claims

Answer

A certification number issued by the American Medical Association

Question 2

What is the difference between a copayment and coinsurance?

Accepted Answer

A copayment is a flat dollar amount paid at the time of service; coinsurance is a percentage of costs shared after the deductible

Answer

A copayment is a percentage; coinsurance is a flat dollar amount

Answer

They are interchangeable terms for the same cost-sharing mechanism

Answer

A copayment applies only to hospital visits; coinsurance applies only to prescriptions

Question 3

A prior authorization is submitted for an MRI and the insurer denies it as 'not medically necessary.' What should the medical administrative specialist do first?

Accepted Answer

File an appeal with supporting clinical documentation from the ordering provider

Answer

Immediately bill the patient for the full cost of the MRI

Answer

Cancel the MRI appointment permanently

Answer

Resubmit the exact same prior authorization request without changes

Question 4

What is a Certificate of Medical Necessity (CMN) primarily used for?

Accepted Answer

Justifying coverage for durable medical equipment (DME) under Medicare

Answer

Documenting a patient's advance directives

Answer

Approving a patient's eligibility for Medicaid

Answer

Authorizing a provider to bill for unlisted procedure codes

Question 5

When verifying insurance for a new patient, the representative states the patient's coverage is 'active but pending.' What should the administrative specialist do?

Accepted Answer

Document the pending status, collect the patient's cost-sharing upfront, and recheck eligibility on the date of service

Answer

Proceed with the appointment and bill the insurance immediately

Answer

Refuse to schedule the patient until coverage is fully confirmed

Answer

Advise the patient to contact their employer directly before coming in

Question 6

Which of the following BEST describes the purpose of a remittance advice (RA) sent from an insurer to a provider?

Accepted Answer

It is a payment explanation detailing how claims were adjudicated and how much was paid or denied

Answer

It notifies the provider of an upcoming audit

Answer

It authorizes the provider to collect the full billed amount from the patient

Answer

It confirms a patient's prior authorization has been approved

Question 7

What is an out-of-pocket maximum in a health insurance plan?

Accepted Answer

The cap on total cost-sharing a patient pays in a plan year, after which insurance covers 100% of covered services

Answer

The maximum amount an employer can contribute to a health savings account annually

Answer

The highest premium a patient can be charged under the ACA

Answer

The maximum number of specialist visits covered per year