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

The NPI is a HIPAA-mandated unique 10-digit number that identifies healthcare providers in standard electronic transactions and must appear on all insurance claims.

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 fixed dollar amount (e.g., $25) paid at each visit, while coinsurance is a percentage (e.g., 20%) of the allowed amount the patient owes after the deductible has been met.

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

When a prior authorization is denied for lack of medical necessity, the next step is to appeal the decision by submitting additional clinical documentation that supports the medical necessity of the requested service.

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

A CMN is a form completed by the ordering physician to document that durable medical equipment (such as a wheelchair or oxygen) is medically necessary for the patient, which is required by Medicare for DME coverage.

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

When coverage is pending, the safest practice is to note the status, collect expected cost-sharing amounts, and re-verify on the date of service to confirm the coverage is fully active before billing.

(CMAS) Certified Medical Administrative Specialist Practice Test

(CMAS) Certified Medical Administrative Specialist Practice Test

CMAS Insurance Verification & Prior Authorization 3