Insurance Verification & Authorization Flashcards

Which federal law requires most employer-sponsored group health plans to offer COBRA continuation coverage after a qualifying event?

Answer: The Consolidated Omnibus Budget Reconciliation Act

COBRA, enacted as part of the Consolidated Omnibus Budget Reconciliation Act, mandates continuation coverage for eligible employees and dependents after qualifying events such as job loss.

During insurance verification, a PAR discovers the patient has both Medicare Part A and an active employer group health plan. Which is typically the primary payer for hospital services if the employer has 20 or more employees?

Answer: The employer group health plan

Under Medicare Secondary Payer rules, an active employer group health plan with 20+ employees is primary to Medicare for working-aged beneficiaries.

A prior authorization is obtained on Monday for a Tuesday elective procedure. The patient's insurance lapses midnight Monday. What is the likely outcome when the claim is submitted?

Answer: The claim will be denied because coverage was not active on the date of service

A prior authorization is not a guarantee of payment; the patient must have active coverage on the date of service for the claim to be reimbursed.

What information does a 'subscriber ID' (member ID) on an insurance card most directly allow the PAR to obtain?

Answer: Eligibility and benefit details through the payer's portal or 270/271 transaction

The subscriber ID is the primary identifier used to query a payer's system via 270/271 electronic transactions or web portals to retrieve eligibility and benefit information.

Under the No Surprises Act, which type of patient situation most directly triggers the Good Faith Estimate requirement for uninsured patients?

Answer: Scheduled non-emergency services requested by an uninsured or self-pay patient

The No Surprises Act requires providers to give Good Faith Estimates to uninsured or self-pay patients scheduling non-emergency services.

A payer's authorization department requests a 'peer-to-peer' review. Who typically participates in this review?

Answer: The ordering physician and the payer's medical director

A peer-to-peer review is a clinical discussion between the ordering physician and the payer's medical director to appeal an authorization denial based on medical necessity.

Which of the following best describes the difference between an 'authorization' and a 'referral' in managed care?

Answer: A referral directs a patient to a specialist; an authorization is payer approval for a service or procedure

A referral is a provider-to-provider direction for specialty care, while an authorization is the insurer's formal approval confirming it will cover a specific service.