Insurance Verification and Authorization Flashcards

Which of the following is the primary reason insurance verification should be completed before the date of service rather than after?

Answer: To identify coverage issues in time to resolve them, collect accurate patient cost-sharing, and reduce claim denials

Pre-service verification allows staff to identify coverage gaps, obtain necessary authorizations, and inform patients of their financial responsibility before care is delivered, reducing denials and bad debt.

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

Answer: An ongoing review by the payer during an inpatient stay to evaluate continued medical necessity

Concurrent review occurs during an inpatient admission, where the payer evaluates whether continued hospitalization is medically necessary on an ongoing basis.

A payer denies a claim stating 'authorization not obtained.' The provider has a confirmed authorization number. What is the most effective initial response?

Answer: Submit an appeal with the authorization number, approval letter, and date of service details

Providing the payer with documented proof of the authorization — including the number, approval date, and confirming representative — is the standard first step in overturning this type of denial.

Under the No Surprises Act, which type of service is most commonly subject to its protections regarding out-of-network charges?

Answer: Emergency services and surprise out-of-network bills at in-network facilities

The No Surprises Act primarily protects patients from unexpected out-of-network bills for emergency services and from out-of-network providers at in-network facilities (e.g., anesthesiologists).

When verifying benefits, a representative notes the patient has a $2,000 deductible with $1,500 already met. What is the patient's remaining deductible responsibility for a $3,000 procedure?

Answer: $500

The remaining deductible is $2,000 − $1,500 = $500, which the patient must pay before the plan's coinsurance or copay structure applies.

Which of the following payer types is most likely to require a Primary Care Physician (PCP) referral before a specialist visit?

Answer: Health Maintenance Organization (HMO)

HMO plans typically require patients to see their assigned PCP first and obtain a formal referral before receiving specialist care.

What information is most critical to document when obtaining a verbal authorization from a payer by phone?

Answer: The authorization number, approved services, date range, representative name, and call reference number

Documenting the authorization number, approved services, effective dates, and the representative's name and call reference creates an auditable record that supports appeals if the authorization is later disputed.