COBGC Payer-Specific Guidelines 3

Question 1

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?

Accepted Answer

Claim will be denied for lack of preauthorization

Answer

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

Question 2

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

Accepted Answer

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

Answer

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

Question 3

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

Accepted Answer

Services are prorated between both insurers based on dates of service

Answer

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.

Question 4

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

Accepted Answer

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

Answer

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.

Question 5

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

Accepted Answer

Claim bundling or 'same-day surgery' bundling policies

Answer

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.

(COBGC) Certified Obstetrics Gynecology Coder Practice Test

(COBGC) Certified Obstetrics Gynecology Coder Practice Test

COBGC Payer-Specific Guidelines 3