CRCR Insurance Verification and Authorization 4 — Questions and Answers
Question 1: A patient's insurance card lists 'Medicaid' as the payer, but the patient also has employer-sponsored insurance. According to COB rules, which plan is typically secondary?
- Employer-sponsored insurance
- Medicaid (Correct answer)
- Both pay equally
- Whichever plan the patient enrolled in first
Correct answer: Medicaid
Medicaid is always the payer of last resort under federal law, meaning it pays only after all other insurance coverage has been applied.
Question 2: Which of the following scenarios would most likely trigger a retroactive eligibility verification?
- Verifying benefits for a scheduled surgery three weeks away
- A claim is denied because the patient's coverage was terminated on the date of service (Correct answer)
- Checking a patient's copay before they check in
- Confirming a referral number for an upcoming specialist visit
Correct answer: A claim is denied because the patient's coverage was terminated on the date of service
When a claim is denied for eligibility reasons after the service has been rendered, staff must perform a retroactive verification to determine whether coverage existed at the time of service.
Question 3: What is the purpose of a 'Level of Care' determination during the authorization process for behavioral health services?
- To set the patient's copay amount for mental health visits
- To establish that the intensity of treatment (e.g., inpatient vs. outpatient) is appropriate for the patient's clinical needs (Correct answer)
- To verify the therapist's license type with the state board
- To determine whether the patient qualifies for Medicaid
Correct answer: To establish that the intensity of treatment (e.g., inpatient vs. outpatient) is appropriate for the patient's clinical needs
A Level of Care determination ensures the proposed setting and intensity of behavioral health treatment are clinically justified and medically necessary per payer criteria.
Question 4: A commercial payer authorizes 10 physical therapy visits. The patient uses all 10 and still needs treatment. What must the provider do before scheduling additional visits?
- Continue scheduling visits since the original condition was already authorized
- Request an extension or additional authorization from the payer for more visits (Correct answer)
- Switch the patient's billing to self-pay for remaining visits
- Obtain a new PCP referral only
Correct answer: Request an extension or additional authorization from the payer for more visits
Once authorized visits are exhausted, the provider must submit clinical documentation to the payer requesting additional visits before more services are rendered to avoid denials.
Question 5: Which of the following best describes a 'payer portal' and its role in insurance verification?
- A government website for reporting insurance fraud
- An online platform provided by the payer that allows providers to check eligibility, authorization status, and claim status in real time (Correct answer)
- A clearinghouse for transmitting 837 claim files
- A database of all credentialed providers in a network
Correct answer: An online platform provided by the payer that allows providers to check eligibility, authorization status, and claim status in real time
Payer portals are web-based tools that give providers direct access to patient eligibility, benefit details, authorization requests, and claim status without calling the payer.
Question 6: A patient calls to dispute that they owe a $350 coinsurance balance. They believe the procedure was fully covered. What is the best first step for the revenue cycle representative?
- Immediately write off the balance to resolve the complaint
- Pull the EOB and compare the patient's plan benefits to the billed services to confirm accurate patient responsibility (Correct answer)
- Transfer the patient to the billing supervisor without reviewing the account
- Instruct the patient to call their insurance company and resolve it themselves
Correct answer: Pull the EOB and compare the patient's plan benefits to the billed services to confirm accurate patient responsibility
Reviewing the Explanation of Benefits alongside the patient's plan benefits allows the representative to verify whether the coinsurance was applied correctly before taking any further action.
Question 7: Under HIPAA, which transaction set is used to electronically check a patient's insurance eligibility and benefit information?
- 837P or 837I (claim submission)
- 270/271 (eligibility inquiry and response) (Correct answer)
- 835 (electronic remittance advice)
- 277 (claim status notification)
Correct answer: 270/271 (eligibility inquiry and response)
The HIPAA 270 transaction is an eligibility inquiry sent to the payer, and the 271 is the payer's response containing the patient's coverage and benefit details.
CRCR Insurance Verification and Authorization 4
A patient's insurance card lists 'Medicaid' as the payer, but the patient also has employer-sponsored insurance.
According to COB rules, which plan is typically secondary?