PACS Insurance Verification & Coverage Criteria 3 — Questions and Answers
Question 1: 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?
- Continue therapy since the original authorization covers the full plan benefit year
- Submit a concurrent review or extension request before the authorized visits are exhausted (Correct answer)
- Discontinue therapy until the new plan year begins
- Bill the additional visits without authorization since therapy is already approved
Correct 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.
Question 2: Which of the following best describes the difference between a precertification and a predetermination in insurance verification?
- Precertification guarantees payment; predetermination is non-binding
- Precertification is required before service and authorizes coverage; predetermination estimates patient cost-sharing but does not guarantee benefits (Correct answer)
- Predetermination is required for all surgical procedures; precertification is optional
- Both terms are interchangeable and have identical legal weight
Correct 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.
Question 3: When verifying coverage for a patient with an Exclusive Provider Organization (EPO) plan, which statement is MOST accurate?
- EPO members may see any provider nationwide without a referral
- EPO members must use in-network providers or services will not be covered except in emergencies (Correct answer)
- EPO plans require a primary care physician referral for all specialist visits
- EPO plans operate identically to HMO plans in all respects
Correct 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.
Question 4: 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?
- The patient does not qualify because BMI is below 40
- The patient may qualify under the BMI ≥35 with comorbidity criterion if supervised weight-loss documentation is complete (Correct answer)
- BMI criteria apply only to Medicare patients, not commercial plans
- The patient qualifies automatically because diabetes is a qualifying comorbidity regardless of BMI
Correct 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.
Question 5: Under the ACA, which category of services must most health plans cover without patient cost-sharing (no copay, deductible, or coinsurance)?
- Specialist office visits for chronic conditions
- Preventive services rated A or B by the U.S. Preventive Services Task Force (USPSTF) (Correct answer)
- All outpatient diagnostic imaging
- Mental health inpatient admissions
Correct 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.
Question 6: A patient with Medicare Part B requires durable medical equipment (DME). Which supplier requirement is essential during insurance verification to ensure Medicare will pay?
- The supplier must be located within 50 miles of the patient's residence
- The supplier must be enrolled as a Medicare-enrolled DME supplier and the equipment must be on the Medicare-approved DME list (Correct answer)
- The patient's physician must be employed by a hospital system to order DME
- DME is covered under Medicare Part A and does not require supplier enrollment
Correct 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.
Question 7: 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?
- Self-funded plans are regulated by state insurance departments and must follow state PA timelines
- Self-funded plans are governed by ERISA and are generally exempt from state insurance mandates, including some PA regulations (Correct answer)
- Self-funded plans cannot require prior authorization for any service
- Self-funded plans must use the same PA criteria as Medicare
Correct 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.
PACS Insurance Verification & Coverage Criteria 3
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?