CRCR Insurance Verification and Authorization 3 — Questions and Answers
Question 1: Which of the following is the primary reason insurance verification should be completed before the date of service rather than after?
- To allow the physician to review the patient's plan details
- To identify coverage issues in time to resolve them, collect accurate patient cost-sharing, and reduce claim denials (Correct answer)
- To ensure the patient's copay is posted to the correct ledger
- To fulfill a Medicare Conditions of Participation requirement
Correct answer: To identify coverage issues in time to resolve them, collect accurate patient cost-sharing, and reduce claim denials
Pre-service verification allows staff to identify coverage gaps, obtain necessary authorizations, and inform patients of their financial responsibility before care is delivered, reducing denials and bad debt.
Question 2: What is a 'concurrent review' in the context of utilization management and authorization?
- A review performed before a service is rendered to determine medical necessity
- An ongoing review by the payer during an inpatient stay to evaluate continued medical necessity (Correct answer)
- A post-discharge audit of clinical documentation
- A second-opinion review by an independent physician
Correct answer: An ongoing review by the payer during an inpatient stay to evaluate continued medical necessity
Concurrent review occurs during an inpatient admission, where the payer evaluates whether continued hospitalization is medically necessary on an ongoing basis.
Question 3: A payer denies a claim stating 'authorization not obtained.' The provider has a confirmed authorization number. What is the most effective initial response?
- Write off the balance as a contractual adjustment
- Submit an appeal with the authorization number, approval letter, and date of service details (Correct answer)
- Re-submit the claim without the authorization number
- Ask the patient to contact their insurance company
Correct answer: Submit an appeal with the authorization number, approval letter, and date of service details
Providing the payer with documented proof of the authorization — including the number, approval date, and confirming representative — is the standard first step in overturning this type of denial.
Question 4: Under the No Surprises Act, which type of service is most commonly subject to its protections regarding out-of-network charges?
- Elective outpatient procedures scheduled weeks in advance
- Emergency services and surprise out-of-network bills at in-network facilities (Correct answer)
- Routine primary care visits
- Prescription drug costs at out-of-network pharmacies
Correct answer: Emergency services and surprise out-of-network bills at in-network facilities
The No Surprises Act primarily protects patients from unexpected out-of-network bills for emergency services and from out-of-network providers at in-network facilities (e.g., anesthesiologists).
Question 5: When verifying benefits, a representative notes the patient has a $2,000 deductible with $1,500 already met. What is the patient's remaining deductible responsibility for a $3,000 procedure?
- $2,000
- $1,500
- $500 (Correct answer)
- $3,000
Correct answer: $500
The remaining deductible is $2,000 − $1,500 = $500, which the patient must pay before the plan's coinsurance or copay structure applies.
Question 6: Which of the following payer types is most likely to require a Primary Care Physician (PCP) referral before a specialist visit?
- Preferred Provider Organization (PPO)
- Health Maintenance Organization (HMO) (Correct answer)
- High-Deductible Health Plan (HDHP)
- Indemnity plan
Correct answer: Health Maintenance Organization (HMO)
HMO plans typically require patients to see their assigned PCP first and obtain a formal referral before receiving specialist care.
Question 7: What information is most critical to document when obtaining a verbal authorization from a payer by phone?
- The payer's mailing address for appeals
- The authorization number, approved services, date range, representative name, and call reference number (Correct answer)
- The patient's social security number and date of birth
- The physician's NPI and DEA number
Correct answer: The authorization number, approved services, date range, representative name, and call reference number
Documenting the authorization number, approved services, effective dates, and the representative's name and call reference creates an auditable record that supports appeals if the authorization is later disputed.
CRCR Insurance Verification and Authorization 3
Which of the following is the primary reason insurance verification should be completed before the date of service rather than after?