Insurance Verification & Coverage Criteria Flashcards

A patient's plan requires prior authorization for genetic testing. The ordering physician submits a PA request citing BRCA1/2 testing for a patient with no personal cancer history but strong family history. Which coverage criterion is MOST relevant to document?

Answer: Personal or family history meeting published clinical guidelines (e.g., NCCN or USPSTF criteria) for hereditary cancer risk

Most payers require documentation that the patient meets established guideline criteria (such as NCCN) for hereditary cancer risk assessment before approving genetic testing.

When verifying Medicaid coverage for a patient, you discover the patient is enrolled in a Medicaid Managed Care Organization (MCO). How does this affect the prior authorization process compared to fee-for-service Medicaid?

Answer: Each MCO may have its own PA requirements, covered services list, and network, requiring verification directly with the MCO rather than the state Medicaid office

Medicaid MCOs contract separately with the state and may impose their own PA criteria, timelines, and network requirements beyond base state Medicaid rules.

A prior authorization specialist receives a PA request for an inpatient psychiatric admission. Under the Mental Health Parity and Addiction Equity Act (MHPAEA), which practice is prohibited?

Answer: Applying more stringent PA criteria or utilization management requirements for mental health benefits than for comparable medical/surgical benefits

MHPAEA prohibits plans from imposing more restrictive quantitative or non-quantitative treatment limitations on mental health/SUD benefits than those applied to analogous medical/surgical benefits.

A PACS specialist verifies that a patient's commercial plan uses InterQual criteria for inpatient medical necessity determinations. What is InterQual?

Answer: A proprietary evidence-based clinical decision-support tool used by payers to evaluate medical necessity for various levels of care

InterQual is a widely-used, evidence-based clinical decision-support tool (published by Change Healthcare/MCG) that payers license to standardize medical necessity reviews.

A patient's plan has an 'embedded deductible' in a family plan. The patient has met her individual deductible but the family deductible is not yet met. How should the specialist interpret this for coverage verification purposes?

Answer: Because the patient has met her individual (embedded) deductible, her claims will be processed at plan benefit levels even if the family deductible remains unmet

In an embedded deductible structure, an individual family member is not required to meet the full family deductible; once their personal deductible is satisfied, benefits apply for that individual.

During coverage verification for home health services, the payer states the patient must be 'homebound' to qualify. Which patient scenario best meets the Medicare homebound definition?

Answer: A patient whose physician certifies that leaving home requires a considerable and taxing effort due to a medical condition

Medicare's homebound criterion requires physician certification that leaving home requires considerable and taxing effort, not merely preference or convenience.

A specialist verifies that a patient's plan requires prior authorization for all non-emergency out-of-network services. The patient received emergency care at an OON facility and was admitted. When does the OON PA requirement typically become applicable during the admission?

Answer: Once the patient is stabilized, the plan may require PA or transfer approval for continued inpatient stay beyond the emergency

Federal law protects the initial emergency episode from PA requirements, but once the patient is stabilized, the plan may impose PA requirements for ongoing inpatient care.