CRCR Insurance Verification and Authorization 2

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?

Accepted Answer

Contact the payer to transfer or obtain a new authorization for the correct facility

Answer

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?

Accepted Answer

A referral is a recommendation from one provider to another, while prior authorization is payer approval for a service

Answer

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?

Accepted Answer

Coordination of Benefits (COB) rules determine the order of payment

Answer

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?

Accepted Answer

Request an extension or a new authorization from the payer before the new surgery date

Answer

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?

Accepted Answer

The provider has not contracted with the patient's insurance plan, often resulting in higher patient cost-sharing

Answer

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.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Insurance Verification and Authorization 2