CRCR CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization 5 — Questions and Answers
Question 1: A verification team member calls a payer and receives eligibility information for a patient. The payer's response is not a guarantee of payment. What term describes this?
- Prior authorization
- Eligibility disclaimer (Correct answer)
- Predetermination of benefits
- Explanation of benefits
Correct answer: Eligibility disclaimer
Payers routinely issue an eligibility disclaimer stating that verification of benefits is not a guarantee of payment, as final payment depends on claim adjudication.
Question 2: Which of the following best describes a 'concurrent review' in the utilization management process?
- A review of medical necessity conducted before a service is rendered
- An ongoing review of a patient's inpatient stay to confirm continued medical necessity (Correct answer)
- A retrospective audit of claims after discharge
- A second-opinion requirement for elective surgery
Correct answer: An ongoing review of a patient's inpatient stay to confirm continued medical necessity
Concurrent review occurs during an inpatient admission to confirm that continued hospitalization is medically necessary, often involving daily or periodic clinical updates to the payer.
Question 3: A patient's insurance card shows 'OON Deductible: $6,000.' The patient insists on seeing an out-of-network specialist. How should the financial counselor frame this information?
- The patient has already met $6,000 of their deductible for out-of-network care
- The patient must pay the first $6,000 of out-of-network costs before the plan contributes to those services (Correct answer)
- Out-of-network services are covered at 100% once the in-network deductible is met
- The $6,000 deductible applies only to prescription drugs
Correct answer: The patient must pay the first $6,000 of out-of-network costs before the plan contributes to those services
An out-of-network deductible means the patient must satisfy $6,000 in OON costs before the plan begins sharing costs for out-of-network services.
Question 4: Under the No Surprises Act, surprise billing protections apply to which of the following scenarios?
- A patient who voluntarily chooses an out-of-network surgeon for a scheduled elective procedure after being informed
- An out-of-network provider who treats a patient at an in-network facility during an emergency without the patient's advance knowledge (Correct answer)
- A patient who travels out of state and sees an out-of-network provider
- An out-of-network provider seen at an out-of-network facility
Correct answer: An out-of-network provider who treats a patient at an in-network facility during an emergency without the patient's advance knowledge
The No Surprises Act protects patients from unexpected bills when an out-of-network provider renders care at an in-network facility without the patient's informed consent.
Question 5: A hospital's insurance verification team uses an automated eligibility system (270/271 transaction set). What standard governs these electronic eligibility transactions?
- ICD-10-CM
- HIPAA ASC X12 5010 (Correct answer)
- HL7 FHIR
- CMS-1450
Correct answer: HIPAA ASC X12 5010
The HIPAA-mandated ASC X12 5010 transaction set defines the 270 (eligibility inquiry) and 271 (eligibility response) electronic data interchange standards.
Question 6: A patient is covered under a PPO plan. During verification, the representative notes the plan has a $30 specialist copay and 20% coinsurance after the deductible. For a $500 specialist visit where the deductible has already been met, what is the patient's estimated liability?
- $30
- $100
- $130 (Correct answer)
- $500
Correct answer: $130
The patient pays the $30 specialist copay plus 20% coinsurance on $500 ($100), totaling $130 in patient liability for this visit.
Question 7: A revenue cycle representative is verifying coverage for a newborn whose parents have not yet notified the insurer of the birth. Under most group health plans, how long do parents typically have to add the newborn to the policy to ensure continuous coverage from birth?
- 7 days
- 30 days (Correct answer)
- 60 days
- 90 days
Correct answer: 30 days
Most group health plans and federal law provide a 30-day special enrollment period for newborns, during which coverage is retroactive to the date of birth if the child is added.
CRCR CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization 5
A verification team member calls a payer and receives eligibility information for a patient.
The payer's response is not a guarantee of payment.
What term describes this?