Insurance Verification & Coverage Criteria Flashcards

A PACS specialist learns that a patient's plan requires prior authorization for MRI of the lumbar spine only when ordered by a primary care physician, but not when ordered by a spine surgeon. What type of PA requirement is this?

Answer: A provider-type-specific PA requirement based on specialty designation

Some plans differentiate PA requirements based on the ordering provider's specialty, applying greater scrutiny when non-specialists order advanced imaging.

During verification, a specialist discovers the patient's plan uses a tiered network with 'Tier 1 preferred' and 'Tier 2 standard' in-network providers. The referred specialist is Tier 2. What is the MOST accurate statement about cost-sharing?

Answer: The patient will pay higher cost-sharing for the Tier 2 provider compared to a Tier 1 provider, but services are still covered in-network

Tiered networks are still in-network but with differential cost-sharing; Tier 2 providers cost the patient more than Tier 1 but less than out-of-network.

A patient's commercial plan denies a PA for a specific brand-name biologic, citing clinical criteria that require documentation of inadequate response to two biosimilars. The prescribing rheumatologist states no biosimilars are available for this specific indication. What is the BEST course of action?

Answer: Submit a medical exception or peer-to-peer review with documented evidence that no biosimilar holds FDA approval for the specific indication

When step therapy requirements are clinically inappropriate (e.g., no biosimilar is FDA-approved for that indication), a medical exception supported by clinical evidence is the proper pathway.

When verifying benefits for an inpatient surgical procedure, which piece of information is MOST important to confirm regarding the anesthesiologist's network status?

Answer: Whether the anesthesiologist participates in the patient's network, since OON anesthesia billing is a common source of surprise bills

Anesthesiologists are a frequent source of surprise out-of-network bills, so verifying their network participation is critical even when the facility and surgeon are in-network.

A PA request is submitted for a home infusion therapy. The payer approves the medication under the pharmacy benefit but the home nursing visits under the medical benefit. What must the PACS specialist verify for each benefit?

Answer: The deductible, copay/coinsurance, and PA requirements may differ between the pharmacy and medical benefit, and each must be verified separately

When a service spans two benefit categories, each benefit has independent cost-sharing and authorization requirements that must be verified separately.

Under the No Surprises Act, which of the following billing scenarios is the act specifically designed to protect patients from?

Answer: Unexpected out-of-network bills from providers at in-network facilities, particularly for emergency care and non-emergency care when no in-network alternative was available

The No Surprises Act protects patients from unexpected OON bills when they receive care at in-network facilities or in emergency situations where they could not choose their provider.

A PACS specialist is verifying insurance for a telehealth behavioral health visit. The patient's plan was issued before March 2020. Which regulatory change most expanded telehealth coverage requirements that the specialist should be aware of?

Answer: COVID-19 public health emergency waivers and subsequent legislative extensions significantly expanded Medicare and commercial telehealth coverage, including coverage parity and geographic flexibility

The COVID-19 PHE waivers and subsequent legislation dramatically broadened telehealth access, including removing geographic restrictions and expanding covered service types for Medicare and many commercial plans.