CPCA Reimbursement and Payer Policies Flashcards

Which term describes the maximum amount a payer will reimburse for a specific service based on fee schedule data?

Answer: Allowed amount

The allowed amount is the maximum the payer will pay for a covered service under their fee schedule.

A dermatology practice submits a claim and receives a payment that is less than the billed amount with no explanation. What should the biller do first?

Answer: Request an Explanation of Benefits (EOB)

Requesting the EOB is the first step to understand why the payer reduced or denied the payment.

Which type of payer plan typically requires patients to select providers from an approved network to receive full benefits?

Answer: Health Maintenance Organization (HMO)

HMOs require members to use in-network providers to receive covered benefits, unlike indemnity plans.

What is the term for the process of verifying a patient's insurance coverage and benefits before services are rendered?

Answer: Eligibility verification

Eligibility verification confirms the patient's active coverage, deductibles, and benefits prior to the appointment.

A payer requires prior authorization for a laser skin resurfacing procedure. What happens if the provider performs the service without obtaining it?

Answer: The claim may be denied entirely

Performing a service without required prior authorization typically results in full claim denial by the payer.

Which Medicare administrative document outlines covered services, billing requirements, and payment rules for specific specialties?

Answer: Local Coverage Determination (LCD)

A Local Coverage Determination (LCD) is issued by Medicare Administrative Contractors to define coverage criteria for specific services.