CRCR Insurance Verification and Authorization 4

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?

Accepted Answer

Medicaid

Answer

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?

Accepted Answer

A claim is denied because the patient's coverage was terminated on the date of service

Answer

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?

Accepted Answer

To establish that the intensity of treatment (e.g., inpatient vs. outpatient) is appropriate for the patient's clinical needs

Answer

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?

Accepted Answer

Request an extension or additional authorization from the payer for more visits

Answer

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?

Accepted Answer

An online platform provided by the payer that allows providers to check eligibility, authorization status, and claim status in real time

Answer

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.

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR - Certified Revenue Cycle Representative Program Practice Test

CRCR Insurance Verification and Authorization 4