Insurance Verification Processes Flashcards

Which government program provides health insurance specifically to individuals aged 65 and older, as well as certain younger individuals with disabilities?

Answer: Medicare

Medicare is the federal health insurance program primarily for people 65 and older, and also covers certain younger individuals with disabilities or end-stage renal disease.

A patient has Medicare Part A and Part B. Which part covers physician office visits?

Answer: Part B

Medicare Part B covers outpatient services including physician office visits, while Part A covers inpatient hospital stays.

When verifying a patient's TRICARE coverage, which unique piece of information is typically required that differs from commercial insurance verification?

Answer: The sponsor's military service branch and ID number

TRICARE coverage is based on the active duty or retired military sponsor's information, requiring the sponsor's branch of service and ID number for verification.

A patient has a $2,000 deductible and has met $1,500 so far this year. The plan pays 80% after the deductible. A bill totals $1,000. How much does the patient owe?

Answer: $600

The patient applies the remaining $500 deductible first, then pays 20% coinsurance on the remaining $500 ($100), totaling $600.

What does 'non-covered service' mean in the context of insurance verification?

Answer: A service excluded from coverage under the patient's plan benefits

Non-covered services are specifically excluded from the patient's benefit plan, meaning the insurer will not pay for them regardless of medical necessity.

A patient presents for a specialist visit but cannot provide a referral. The PAR confirms the plan requires referrals. What is the BEST course of action?

Answer: Contact the patient's PCP to obtain the referral before or document the attempt before proceeding

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

Which of the following best describes 'real-time eligibility verification' (RTE)?

Answer: Electronically querying a payer's system to receive instant coverage information

Real-time eligibility verification uses electronic data interchange (EDI) to receive instant responses from payers about a patient's current coverage.