Insurance Verification and Authorization Flashcards

A patient presents for an elective MRI. The payer requires prior authorization, but the authorization was obtained for a different facility. What is the most appropriate action?

Answer: Contact the payer to transfer or obtain a new authorization for the correct facility

Authorization is typically site-specific, so a new or transferred authorization must be obtained from the payer before proceeding at the correct facility.

Which of the following is a key difference between a referral and a prior authorization?

Answer: A referral is a recommendation from one provider to another, while prior authorization is payer approval for a service

A referral is a clinical recommendation from one provider directing a patient to another, whereas prior authorization is formal payer approval that a service is medically necessary.

During insurance verification, a representative discovers the patient has both Medicare and a commercial plan. Which principle determines which payer pays first?

Answer: Coordination of Benefits (COB) rules determine the order of payment

Coordination of Benefits (COB) rules established by CMS and state regulations govern which payer is primary and which is secondary when a patient has dual coverage.

A prior authorization for a surgical procedure was approved, but the surgery date was pushed back two weeks beyond the authorization's expiration date. What should the revenue cycle representative do?

Answer: Request an extension or a new authorization from the payer before the new surgery date

Expired authorizations are not valid; the representative must contact the payer to extend or reissue the authorization before the service is rendered.

What does 'out-of-network' status mean in the context of insurance verification?

Answer: The provider has not contracted with the patient's insurance plan, often resulting in higher patient cost-sharing

An out-of-network provider has no contracted rate with the payer, which typically results in higher deductibles, coinsurance, or full patient responsibility depending on the plan.

Which document should a revenue cycle representative review to understand the specific services a patient's plan covers or excludes?

Answer: The Summary of Benefits and Coverage (SBC) or the plan's benefit booklet

The Summary of Benefits and Coverage or the full plan benefit booklet outlines covered services, exclusions, and cost-sharing requirements for a patient's specific plan.

A payer's automated eligibility response shows 'inactive' for a patient who claims to have active coverage. What is the best next step?

Answer: Call the payer directly to manually verify the patient's eligibility status

Automated eligibility systems can lag or have errors, so a direct call to the payer is the appropriate step to confirm actual coverage status before denying care.