Insurance Verification and Authorization Flashcards

A patient's insurance card lists 'Medicaid' as the payer, but the patient also has employer-sponsored insurance. According to COB rules, which plan is typically secondary?

Answer: Medicaid

Medicaid is always the payer of last resort under federal law, meaning it pays only after all other insurance coverage has been applied.

Which of the following scenarios would most likely trigger a retroactive eligibility verification?

Answer: A claim is denied because the patient's coverage was terminated on the date of service

When a claim is denied for eligibility reasons after the service has been rendered, staff must perform a retroactive verification to determine whether coverage existed at the time of service.

What is the purpose of a 'Level of Care' determination during the authorization process for behavioral health services?

Answer: To establish that the intensity of treatment (e.g., inpatient vs. outpatient) is appropriate for the patient's clinical needs

A Level of Care determination ensures the proposed setting and intensity of behavioral health treatment are clinically justified and medically necessary per payer criteria.

A commercial payer authorizes 10 physical therapy visits. The patient uses all 10 and still needs treatment. What must the provider do before scheduling additional visits?

Answer: Request an extension or additional authorization from the payer for more visits

Once authorized visits are exhausted, the provider must submit clinical documentation to the payer requesting additional visits before more services are rendered to avoid denials.

Which of the following best describes a 'payer portal' and its role in insurance verification?

Answer: An online platform provided by the payer that allows providers to check eligibility, authorization status, and claim status in real time

Payer portals are web-based tools that give providers direct access to patient eligibility, benefit details, authorization requests, and claim status without calling the payer.

A patient calls to dispute that they owe a $350 coinsurance balance. They believe the procedure was fully covered. What is the best first step for the revenue cycle representative?

Answer: Pull the EOB and compare the patient's plan benefits to the billed services to confirm accurate patient responsibility

Reviewing the Explanation of Benefits alongside the patient's plan benefits allows the representative to verify whether the coinsurance was applied correctly before taking any further action.

Under HIPAA, which transaction set is used to electronically check a patient's insurance eligibility and benefit information?

Answer: 270/271 (eligibility inquiry and response)

The HIPAA 270 transaction is an eligibility inquiry sent to the payer, and the 271 is the payer's response containing the patient's coverage and benefit details.