CRCR CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization 3

Question 1

A patient presents for an elective MRI. During insurance verification, the representative discovers the patient's plan requires a referral from the PCP before seeing a specialist. What is the correct next step?

Accepted Answer

Contact the patient to obtain a valid PCP referral before the service date

Answer

When a plan requires a PCP referral, the representative must ensure it is obtained prior to the service to prevent a denial.

Question 2

Which document is most commonly used by providers to formally request prior authorization from a payer?

Accepted Answer

Prior authorization request form or payer-specific portal submission

Answer

Prior authorization is requested through the payer's designated form or online portal, not through claim forms.

Question 3

A verification specialist confirms a patient has two active insurance plans. Under the Coordination of Benefits (COB) rule, which plan pays first for a dependent child when both parents have insurance?

Accepted Answer

The plan of the parent whose birthday falls earlier in the year (birthday rule)

Answer

The birthday rule states that the parent whose birthday (month and day) falls earlier in the calendar year has the primary plan for a dependent child.

Question 4

A prior authorization is obtained for a 3-unit outpatient infusion. The physician increases the dosage and administers 5 units. What is the likely billing outcome?

Accepted Answer

Units beyond the authorized amount will likely be denied unless a new authorization is obtained

Answer

Authorization is typically limited to the approved quantity; units exceeding the authorization require a new or amended prior authorization.

Question 5

What is a 'gap exception' in the context of insurance verification?

Accepted Answer

A waiver allowing out-of-network providers to be reimbursed at in-network rates when no in-network provider is available

Answer

A gap exception (or network gap exception) allows patients to receive in-network benefit levels when no in-network provider is reasonably available for a needed service.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization 3