CRCR Insurance Verification and Authorization 3

Question 1

Which of the following is the primary reason insurance verification should be completed before the date of service rather than after?

Accepted Answer

To identify coverage issues in time to resolve them, collect accurate patient cost-sharing, and reduce claim denials

Answer

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?

Accepted Answer

An ongoing review by the payer during an inpatient stay to evaluate continued medical necessity

Answer

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?

Accepted Answer

Submit an appeal with the authorization number, approval letter, and date of service details

Answer

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?

Accepted Answer

Emergency services and surprise out-of-network bills at in-network facilities

Answer

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?

Accepted Answer

$500

Answer

The remaining deductible is $2,000 − $1,500 = $500, which the patient must pay before the plan's coinsurance or copay structure applies.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Insurance Verification and Authorization 3