CRCR Insurance Verification and Authorization 2 — Questions and Answers
Question 1: A patient presents for an elective MRI. The payer requires prior authorization, but the authorization was obtained for a different facility. What is the most appropriate action?
- Proceed with the MRI since authorization was already obtained
- Contact the payer to transfer or obtain a new authorization for the correct facility (Correct answer)
- Cancel the appointment and reschedule for another day
- Bill without authorization and appeal if denied
Correct answer: Contact the payer to transfer or obtain a new authorization for the correct facility
Authorization is typically site-specific, so a new or transferred authorization must be obtained from the payer before proceeding at the correct facility.
Question 2: Which of the following is a key difference between a referral and a prior authorization?
- A referral is obtained from the payer, while prior authorization is obtained from the PCP
- A referral is a recommendation from one provider to another, while prior authorization is payer approval for a service (Correct answer)
- A referral guarantees payment, while prior authorization does not
- Prior authorization is only required for inpatient services
Correct answer: A referral is a recommendation from one provider to another, while prior authorization is payer approval for a service
A referral is a clinical recommendation from one provider directing a patient to another, whereas prior authorization is formal payer approval that a service is medically necessary.
Question 3: During insurance verification, a representative discovers the patient has both Medicare and a commercial plan. Which principle determines which payer pays first?
- The patient selects their preferred primary payer
- Coordination of Benefits (COB) rules determine the order of payment (Correct answer)
- Medicare always pays first regardless of other coverage
- The commercial plan always pays first as a secondary payer
Correct answer: Coordination of Benefits (COB) rules determine the order of payment
Coordination of Benefits (COB) rules established by CMS and state regulations govern which payer is primary and which is secondary when a patient has dual coverage.
Question 4: A prior authorization for a surgical procedure was approved, but the surgery date was pushed back two weeks beyond the authorization's expiration date. What should the revenue cycle representative do?
- Use the existing authorization since it was approved for the same procedure
- Request an extension or a new authorization from the payer before the new surgery date (Correct answer)
- Document the expired authorization and bill anyway
- Have the physician sign a waiver to replace the authorization
Correct answer: Request an extension or a new authorization from the payer before the new surgery date
Expired authorizations are not valid; the representative must contact the payer to extend or reissue the authorization before the service is rendered.
Question 5: What does 'out-of-network' status mean in the context of insurance verification?
- The provider has no active license in the patient's state
- The provider has not contracted with the patient's insurance plan, often resulting in higher patient cost-sharing (Correct answer)
- The patient's insurance has lapsed
- The service is excluded from all insurance coverage
Correct answer: The provider has not contracted with the patient's insurance plan, often resulting in higher patient cost-sharing
An out-of-network provider has no contracted rate with the payer, which typically results in higher deductibles, coinsurance, or full patient responsibility depending on the plan.
Question 6: Which document should a revenue cycle representative review to understand the specific services a patient's plan covers or excludes?
- The explanation of benefits (EOB) from a prior claim
- The Summary of Benefits and Coverage (SBC) or the plan's benefit booklet (Correct answer)
- The provider's credentialing file
- The patient's discharge summary
Correct answer: The Summary of Benefits and Coverage (SBC) or the plan's benefit booklet
The Summary of Benefits and Coverage or the full plan benefit booklet outlines covered services, exclusions, and cost-sharing requirements for a patient's specific plan.
Question 7: A payer's automated eligibility response shows 'inactive' for a patient who claims to have active coverage. What is the best next step?
- Deny coverage and ask the patient to pay in full
- Call the payer directly to manually verify the patient's eligibility status (Correct answer)
- Proceed with the visit and bill the patient after the fact
- Request a new insurance card and re-verify in 30 days
Correct answer: Call the payer directly to manually verify the patient's eligibility status
Automated eligibility systems can lag or have errors, so a direct call to the payer is the appropriate step to confirm actual coverage status before denying care.
CRCR Insurance Verification and Authorization 2
A patient presents for an elective MRI.
The payer requires prior authorization, but the authorization was obtained for a different facility.
What is the most appropriate action?