Insurance Verification & Authorization Flashcards

A patient presents with two active insurance plans. Which coordination of benefits rule determines the primary payer when both plans cover the same individual as a subscriber?

Answer: The plan held longest pays primary

Under coordination of benefits, the plan the patient has held the longest is designated as the primary payer when both plans cover the individual as a subscriber.

When verifying benefits for a patient covered under a grandfathered health plan, which ACA-mandated benefit may NOT be required?

Answer: Preventive care with no cost-sharing

Grandfathered plans are exempt from the ACA requirement to cover preventive services without cost-sharing, though they must still cover pre-existing conditions.

A prior authorization is approved for a lumbar MRI, but the ordering physician changes the imaging site to a non-participating facility. What is the most appropriate action?

Answer: Obtain a new authorization for the updated facility

Authorizations are typically site-specific, so a change in facility requires obtaining a new prior authorization from the payer.

Which document should a Patient Access Representative request to verify that a commercial insurance plan has accepted assignment of benefits?

Answer: Assignment of Benefits form signed by the patient

A signed Assignment of Benefits form authorizes the insurer to pay the provider directly rather than reimbursing the patient.

An insurer's eligibility response shows 'coverage terminated.' The patient insists coverage is active. What is the best next step?

Answer: Call the insurer's provider line to manually verify coverage

Calling the insurer directly to manually verify allows the representative to resolve potential data entry errors or system lag in real time.

What is the purpose of a 'Level of Care' determination in the prior authorization process for inpatient admissions?

Answer: To determine whether the admission meets medical necessity criteria for the requested level

A Level of Care determination evaluates whether the clinical documentation supports medical necessity for inpatient versus observation or outpatient care.

A patient's Medicaid managed care plan requires a referral from the primary care physician (PCP) before seeing a specialist. The patient arrives without a referral. What should the PAR do?

Answer: Contact the PCP's office to obtain a same-day referral before providing non-emergency services

Contacting the PCP to obtain a valid referral protects both the patient and the facility from a claim denial due to missing authorization.