Insurance Verification & Authorization Flashcards

A patient's plan has an out-of-pocket maximum of $6,000. They have already paid $5,800 toward covered services this plan year. What is the patient's remaining financial responsibility for the next covered in-network claim?

Answer: $200, then the plan covers 100% of covered in-network services

Once a patient's accumulated cost-sharing reaches the out-of-pocket maximum, they owe only the remaining $200 before the insurer covers 100% of in-network covered services for the rest of the plan year.

What is the standard ANSI X12 transaction set used to request real-time insurance eligibility and benefit information from a payer?

Answer: 270/271

The 270 transaction is the electronic eligibility inquiry sent to a payer, and the 271 is the payer's response with coverage details.

A patient with Medicaid presents for an elective procedure. The PAR cannot verify active Medicaid eligibility on the date of service. What is the most appropriate action?

Answer: Attempt to verify through the state Medicaid portal or EVS before providing non-emergency services

Medicaid eligibility must be confirmed for each date of service via the state's Eligibility Verification System (EVS) before providing non-emergency services.

Which term describes the process by which a health plan reviews submitted documentation after a service is rendered to determine if the care met medical necessity criteria?

Answer: Retrospective review

Retrospective review occurs after care has been delivered and evaluates whether the services met the payer's medical necessity criteria for reimbursement.

When a payer issues an 'Adverse Determination' for a prior authorization request, what is the patient's and provider's first available recourse?

Answer: File an internal appeal with the payer within the required timeframe

An internal appeal to the payer is the required first step after an adverse determination before external review or regulatory complaints can be pursued.

A patient covered by a PPO plan seeks care from an out-of-network provider. Which statement about their cost-sharing is most accurate?

Answer: The patient typically pays higher cost-sharing and may owe balance billing charges from the provider

PPO members can use out-of-network providers but face a higher deductible, higher coinsurance, and potential balance billing since out-of-network providers are not bound by the plan's contracted rates.

A physician office submits a request for authorization of a sleep study. The payer requires that conservative treatments be documented as tried and failed before approving. This is an example of which type of utilization management criteria?

Answer: Step therapy (fail-first) criteria

Step therapy, or fail-first criteria, requires documentation that less intensive or less costly treatments were attempted without success before the payer approves a more advanced service.