CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization Flashcards
6 cards from real CRCR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization flashcards as text
What is the difference between a referral and a prior authorization?
Answer: A referral is a physician's order to see a specialist; prior authorization is payer approval for a specific service or procedure
Referrals come from physicians directing patients to specialists; prior authorizations are payer approvals for specific services.
What information must typically be included when submitting a prior authorization request to an insurer?
Answer: The patient's demographics, insurance information, provider NPI, requested service CPT code, diagnosis codes, and clinical justification
Prior auth submissions require complete clinical and administrative information to allow the payer to make a coverage determination.
What is an authorization number and how is it used in the billing process?
Answer: A payer-issued approval number that must be included on the claim to confirm the service was pre-authorized
The authorization number confirms payer approval and must be submitted on the claim to prevent an authorization-related denial.
Why is it important to verify insurance eligibility on the date of service, not just at the time of scheduling?
Answer: Insurance coverage can change between scheduling and the service date due to job loss, open enrollment changes, or premium non-payment
Insurance coverage can change between scheduling and the service date and verifying on the date of service prevents billing to inactive or changed coverage.
What is a gap in authorization and how does it affect revenue cycle?
Answer: A situation where authorized services end before the patient is ready for discharge requiring additional authorization to cover remaining days or services
A gap in authorization occurs when approved services expire before the episode of care is complete requiring timely action to extend authorization.
When a payer denies prior authorization for a service the physician believes is medically necessary, what option is available to the provider?
Answer: The provider can request a peer-to-peer review between the treating physician and the payer's medical director
A peer-to-peer review allows the treating physician to directly discuss the clinical rationale with the payer's medical director to seek reversal of the denial.