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

A verification team member calls a payer and receives eligibility information for a patient. The payer's response is not a guarantee of payment. What term describes this?

Answer: Eligibility disclaimer

Payers routinely issue an eligibility disclaimer stating that verification of benefits is not a guarantee of payment, as final payment depends on claim adjudication.

Which of the following best describes a 'concurrent review' in the utilization management process?

Answer: An ongoing review of a patient's inpatient stay to confirm continued medical necessity

Concurrent review occurs during an inpatient admission to confirm that continued hospitalization is medically necessary, often involving daily or periodic clinical updates to the payer.

A patient's insurance card shows 'OON Deductible: $6,000.' The patient insists on seeing an out-of-network specialist. How should the financial counselor frame this information?

Answer: The patient must pay the first $6,000 of out-of-network costs before the plan contributes to those services

An out-of-network deductible means the patient must satisfy $6,000 in OON costs before the plan begins sharing costs for out-of-network services.

Under the No Surprises Act, surprise billing protections apply to which of the following scenarios?

Answer: An out-of-network provider who treats a patient at an in-network facility during an emergency without the patient's advance knowledge

The No Surprises Act protects patients from unexpected bills when an out-of-network provider renders care at an in-network facility without the patient's informed consent.

A hospital's insurance verification team uses an automated eligibility system (270/271 transaction set). What standard governs these electronic eligibility transactions?

Answer: HIPAA ASC X12 5010

The HIPAA-mandated ASC X12 5010 transaction set defines the 270 (eligibility inquiry) and 271 (eligibility response) electronic data interchange standards.

A patient is covered under a PPO plan. During verification, the representative notes the plan has a $30 specialist copay and 20% coinsurance after the deductible. For a $500 specialist visit where the deductible has already been met, what is the patient's estimated liability?

Answer: $130

The patient pays the $30 specialist copay plus 20% coinsurance on $500 ($100), totaling $130 in patient liability for this visit.

A revenue cycle representative is verifying coverage for a newborn whose parents have not yet notified the insurer of the birth. Under most group health plans, how long do parents typically have to add the newborn to the policy to ensure continuous coverage from birth?

Answer: 30 days

Most group health plans and federal law provide a 30-day special enrollment period for newborns, during which coverage is retroactive to the date of birth if the child is added.