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

A patient scheduled for an inpatient admission has Medicare as primary and Medicaid as secondary. The hospital verifies Medicare eligibility but skips Medicaid verification. What risk does this create?

Answer: The hospital may miss cost-sharing amounts Medicaid would cover, leaving a balance the patient cannot afford

Failing to verify Medicaid eligibility may result in the provider not billing Medicaid for cost-sharing, leaving the patient with a balance they are often legally protected from owing.

An authorization number is obtained for a colonoscopy coded as a screening procedure. The physician finds and removes a polyp, changing the code to a therapeutic procedure. What should the revenue cycle team do?

Answer: Contact the payer to update or obtain a new authorization for the changed procedure code

When the procedure code changes materially, the payer must be notified and a new or amended authorization obtained to avoid denial.

Which verification element confirms that the specific provider or facility is contracted with the patient's insurance plan?

Answer: Network/participation status verification

Network or participation status verification confirms whether the provider is in-network with the patient's plan, affecting the benefit level the patient receives.

A payer denies a claim stating 'authorization not obtained.' The revenue cycle team confirms they received a verbal authorization. What is the best course of action?

Answer: Appeal with documentation of the verbal authorization, including date, time, and representative name

Verbal authorizations, when properly documented with the reference number and representative information, can support an appeal of a denial.

What is the primary purpose of obtaining a patient's insurance ID card at registration?

Answer: To verify the member ID, group number, and payer contact information needed for eligibility checks

The insurance ID card provides key identifiers—member ID, group number, and payer phone/portal information—required to conduct an accurate eligibility verification.

A self-funded employer plan denies a prior authorization request. Under ERISA, the plan is governed by federal law. Which entity has regulatory authority over self-funded plan authorization denials?

Answer: U.S. Department of Labor (DOL)

Self-funded employer plans are governed by ERISA and regulated by the U.S. Department of Labor, not state insurance regulators.

When verifying benefits for a patient with a high-deductible health plan (HDHP) paired with an HSA, what is a key financial counseling point the revenue cycle staff should communicate?

Answer: The patient can use HSA funds to pay qualified medical expenses, including deductibles and copays, tax-free

HSA funds are available tax-free for qualified medical expenses, including deductibles and copays, and communicating this helps patients plan for cost-sharing.