Payer-Specific Guidelines Flashcards

A patient's commercial plan requires preauthorization for a hysteroscopy with polypectomy. The surgeon performs the procedure without obtaining auth. What is the most likely outcome?

Answer: Claim will be denied for lack of preauthorization

Commercial payers will typically deny a claim outright when a required prior authorization was not obtained, regardless of the medical necessity of the procedure.

UnitedHealthcare's clinical policy commonly requires what documentation before approving a laparoscopic hysterectomy for abnormal uterine bleeding?

Answer: Documentation of failed conservative treatments such as hormonal therapy and/or endometrial ablation

UHC and most major commercial payers require evidence that conservative, less-invasive treatments have been attempted and failed before approving hysterectomy for AUB.

Under most commercial plans, how is the global obstetric package typically handled when a patient switches insurance mid-pregnancy?

Answer: Services are prorated between both insurers based on dates of service

When a patient changes insurers during pregnancy, each insurer pays for the services rendered during its coverage period, requiring the global package to be unbundled and billed by date of service.

An Aetna member receives an out-of-network cesarean delivery due to an emergency. How will Aetna most likely process this claim?

Answer: Pay at the in-network benefit level because it was an emergency

Federal law (and most state laws) require commercial insurers to cover emergency services at the in-network benefit level, regardless of whether the provider is in-network.

Blue Cross Blue Shield plans often use which concept to bundle related gynecologic services performed on the same day, preventing separate billing?

Answer: Claim bundling or 'same-day surgery' bundling policies

BCBS and other commercial payers apply claim bundling policies that combine multiple related procedures performed on the same day into a single allowable, preventing double-billing.

A commercial payer's explanation of benefits (EOB) shows a 'COB adjustment' on a claim for an OB delivery. What does this indicate?

Answer: Coordination of Benefits rules were applied because the patient has more than one insurance policy

A COB adjustment on an EOB means the payer has applied coordination of benefits rules because the patient has dual coverage, adjusting payment based on what the primary payer already paid.

When billing a commercial payer for a vaginal delivery with an episiotomy repair, how is the episiotomy typically handled?

Answer: Bundled into the vaginal delivery code and not separately billable

Episiotomy and its repair are considered integral to the vaginal delivery procedure and are bundled into the global obstetric or delivery code by virtually all payers.