CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization Flashcards

A patient presents for an elective MRI. During insurance verification, the representative discovers the patient's plan requires a referral from the PCP before seeing a specialist. What is the correct next step?

Answer: Contact the patient to obtain a valid PCP referral before the service date

When a plan requires a PCP referral, the representative must ensure it is obtained prior to the service to prevent a denial.

Which document is most commonly used by providers to formally request prior authorization from a payer?

Answer: Prior authorization request form or payer-specific portal submission

Prior authorization is requested through the payer's designated form or online portal, not through claim forms.

A verification specialist confirms a patient has two active insurance plans. Under the Coordination of Benefits (COB) rule, which plan pays first for a dependent child when both parents have insurance?

Answer: The plan of the parent whose birthday falls earlier in the year (birthday rule)

The birthday rule states that the parent whose birthday (month and day) falls earlier in the calendar year has the primary plan for a dependent child.

A prior authorization is obtained for a 3-unit outpatient infusion. The physician increases the dosage and administers 5 units. What is the likely billing outcome?

Answer: Units beyond the authorized amount will likely be denied unless a new authorization is obtained

Authorization is typically limited to the approved quantity; units exceeding the authorization require a new or amended prior authorization.

What is a 'gap exception' in the context of insurance verification?

Answer: A waiver allowing out-of-network providers to be reimbursed at in-network rates when no in-network provider is available

A gap exception (or network gap exception) allows patients to receive in-network benefit levels when no in-network provider is reasonably available for a needed service.

During eligibility verification, the representative finds that the patient's policy has a $2,000 individual deductible with $1,500 already met. The service costs $800. What is the patient's estimated deductible liability?

Answer: $500

The remaining deductible is $500 ($2,000 − $1,500), which is less than the $800 service cost, so the patient owes $500 toward the deductible.

Which federal law requires that mental health benefits be offered at parity with medical/surgical benefits, directly affecting insurance verification for behavioral health services?

Answer: Mental Health Parity and Addiction Equity Act (MHPAEA)

The MHPAEA mandates that financial requirements and treatment limitations for mental health and substance use disorder benefits are no more restrictive than those for medical/surgical benefits.