Insurance Verification & Coverage Criteria Flashcards

A prior authorization is approved for 12 physical therapy visits. After visit 8, the therapist believes 8 additional visits are needed. What is the CORRECT action?

Answer: Submit a concurrent review or extension request before the authorized visits are exhausted

Concurrent review or an extension request must be submitted while authorized visits remain to avoid a gap in coverage or retrospective denial.

Which of the following best describes the difference between a precertification and a predetermination in insurance verification?

Answer: Precertification is required before service and authorizes coverage; predetermination estimates patient cost-sharing but does not guarantee benefits

Precertification authorizes a service as medically necessary, while predetermination is a non-binding cost estimate that does not constitute a promise of payment.

When verifying coverage for a patient with an Exclusive Provider Organization (EPO) plan, which statement is MOST accurate?

Answer: EPO members must use in-network providers or services will not be covered except in emergencies

EPO plans restrict coverage to in-network providers (no out-of-network coverage except emergencies) but generally do not require PCP referrals, unlike HMOs.

A PACS specialist is reviewing coverage criteria for bariatric surgery. The plan requires a BMI of ≥40 or ≥35 with comorbidities and 6 months of supervised weight-loss program documentation. The patient's BMI is 36 with documented Type 2 diabetes. Which criterion applies?

Answer: The patient may qualify under the BMI ≥35 with comorbidity criterion if supervised weight-loss documentation is complete

A BMI of 36 with Type 2 diabetes meets the ≥35 with comorbidity threshold, but the 6-month supervised program documentation must also be submitted.

Under the ACA, which category of services must most health plans cover without patient cost-sharing (no copay, deductible, or coinsurance)?

Answer: Preventive services rated A or B by the U.S. Preventive Services Task Force (USPSTF)

The ACA mandates that non-grandfathered plans cover USPSTF A/B-rated preventive services without any patient cost-sharing.

A patient with Medicare Part B requires durable medical equipment (DME). Which supplier requirement is essential during insurance verification to ensure Medicare will pay?

Answer: The supplier must be enrolled as a Medicare-enrolled DME supplier and the equipment must be on the Medicare-approved DME list

Medicare will only reimburse DME from suppliers enrolled in the Medicare program, and the item must appear on Medicare's list of covered equipment.

During an eligibility verification call, the payer representative states the patient's plan is 'self-funded.' What is the primary regulatory implication for prior authorization?

Answer: Self-funded plans are governed by ERISA and are generally exempt from state insurance mandates, including some PA regulations

ERISA preempts state insurance laws for self-funded employer plans, meaning state-mandated PA timelines and coverage rules may not apply.