CRCR CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization 2

Question 1

What is the purpose of reviewing an Explanation of Benefits during the insurance verification process?

Accepted Answer

To understand how a patient's plan pays for specific services and what the patient's cost-sharing responsibilities are

Answer

To confirm the patient's demographic information

Answer

To determine the patient's credit score

Answer

To verify the physician's NPI number

Question 2

A patient's insurance verification reveals a $2,500 deductible with $1,800 already met for the year. What is the patient's remaining deductible exposure?

Accepted Answer

$700

Answer

$2,500

Answer

$1,800

Answer

$0

Question 3

What does in-network versus out-of-network mean for a patient seeking services?

Accepted Answer

In-network providers have a contracted rate with the patient's insurer resulting in lower cost-sharing; out-of-network providers may cost significantly more

Answer

In-network means the provider accepts cash only; out-of-network means the provider accepts insurance

Answer

In-network services are always covered at 100%; out-of-network services are never covered

Answer

In-network and out-of-network terms only apply to HMO plans

Question 4

Which information is typically required when calling a payer to verify insurance eligibility?

Accepted Answer

The patient's name, date of birth, insurance ID number, and the provider's NPI

Answer

The patient's credit card number and billing address

Answer

The patient's prior authorization number and claim history

Answer

The patient's primary care physician's license number

Question 5

What is the consequence of billing a service that required prior authorization but for which authorization was not obtained?

Accepted Answer

The claim will typically be denied and the provider may be responsible for writing off the balance

Answer

The claim will be paid at the standard rate

Answer

The patient automatically owes the full billed charge

Answer

The claim will be paid after the deductible is met

Question 6

What is concurrent review in the context of utilization management and prior authorization?

Accepted Answer

A review conducted during an inpatient stay to determine if continued hospitalization is medically necessary

Answer

A review of claims after discharge to determine if the admission was appropriate

Answer

A review of the patient's financial capacity before admission

Answer

A comparison of two different insurance plans for coverage purposes