CRCR CRCR - Certified Revenue Cycle Representative Program Insurance Verification and Authorization 5

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?

Accepted Answer

Eligibility disclaimer

Answer

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?

Accepted Answer

An ongoing review of a patient's inpatient stay to confirm continued medical necessity

Answer

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?

Accepted Answer

The patient must pay the first $6,000 of out-of-network costs before the plan contributes to those services

Answer

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?

Accepted Answer

An out-of-network provider who treats a patient at an in-network facility during an emergency without the patient's advance knowledge

Answer

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?

Accepted Answer

HIPAA ASC X12 5010

Answer

The HIPAA-mandated ASC X12 5010 transaction set defines the 270 (eligibility inquiry) and 271 (eligibility response) electronic data interchange standards.

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 5