Financial Clearance and Counseling Flashcards

A patient's employer-sponsored plan is their primary insurance, and their spouse's plan is secondary. Under the birthday rule for a dependent child, which plan is primary?

Answer: The plan of the parent whose birthday falls earlier in the calendar year

The birthday rule states that the parent whose birthday (month and day) falls earlier in the calendar year holds the primary plan for a dependent child.

COBRA allows eligible employees who lose job-based coverage to do which of the following?

Answer: Continue their employer's group health plan for a limited period by paying the full premium

COBRA provides continuation of group health coverage for a limited time when coverage would otherwise be lost due to qualifying life events, but the individual pays the full premium.

Which of the following is an example of a 'clean claim' in medical billing?

Answer: A claim that contains all required fields with no errors and passes payer edits on first submission

A clean claim is one that is complete, accurate, and passes all payer edits upon first submission, allowing for prompt payment.

What is the significance of verifying a patient's insurance eligibility at each visit rather than only at registration?

Answer: Coverage can lapse or change between visits, which would affect billing and patient liability

Insurance status can change due to job loss, open enrollment changes, or non-payment of premiums, making verification at every visit essential to accurate billing.

A patient with Medicaid requests an elective cosmetic procedure. What should the PAR advise?

Answer: Medicaid generally does not cover elective cosmetic procedures; the patient would likely be responsible for the full cost

Medicaid covers medically necessary services; elective cosmetic procedures are typically excluded and would be the patient's financial responsibility.

Which term describes the maximum dollar amount an insurance plan will pay for a covered service based on what is considered reasonable in a geographic area?

Answer: Usual, Customary, and Reasonable (UCR) amount

The Usual, Customary, and Reasonable (UCR) amount is the benchmark insurers use to determine the maximum reimbursable charge for a service in a given area.

A patient indicates they are covered under Workers' Compensation for an injury sustained at work. Which payer should be billed first?

Answer: Workers' Compensation

Workers' Compensation is the primary payer for work-related injuries and must be billed before any other health insurance plan.