PAR PAR Denial Management and Point of Service Collections 2

Question 1

What is 'balance billing' and when is it prohibited?

Accepted Answer

Charging a patient the difference between a provider's billed charge and the insurer's allowed amount; prohibited for in-network providers under most contracts

Answer

Balance billing charges patients more than the contracted rate, and in-network providers are contractually prohibited from billing patients beyond their required cost-sharing (deductible, copay, coinsurance).

Question 2

Under the 'birthday rule' for COB, how is the primary insurer determined for a dependent child?

Accepted Answer

The parent whose birthday falls earlier in the calendar year has the primary plan for the dependent child

Answer

The birthday rule states that when a child is covered under both parents' plans, the plan of the parent whose birthday (month and day) falls first in the calendar year is primary.

Question 3

What is 'subrogation' in the context of health insurance?

Accepted Answer

The right of an insurer to seek reimbursement from a liable third party after paying a claim on behalf of the insured

Answer

Subrogation allows an insurer that paid a medical claim to recover those costs from a third party (such as a liability insurer) that is ultimately responsible for the injury.

Question 4

What is 'medical necessity' and why does it matter for claims?

Accepted Answer

Services or supplies that are appropriate and consistent with the diagnosis, meeting accepted standards of care; required for insurers to pay claims

Answer

Medical necessity means that a service is appropriate, reasonable, and consistent with evidence-based clinical standards, and payers require it to be established before paying claims.

Question 5

What is an 'appeal' in the medical billing process?

Accepted Answer

A formal request to an insurer to reconsider a denied or underpaid claim with supporting clinical or administrative documentation

Answer

An appeal is a written request submitted to a payer asking them to overturn a denial or increase reimbursement, typically accompanied by supporting clinical documentation or coding rationale.

(PAR) Patient Access Representative Certification Practice Test

(PAR) Patient Access Representative Certification Practice Test

PAR PAR Denial Management and Point of Service Collections 2