PAR Insurance Verification & Authorization 2 — Questions and Answers
Question 1: 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?
- The plan with the later effective date pays first
- The plan held longest pays primary (Correct answer)
- The plan with the lower deductible pays primary
- The patient chooses which plan pays first
Correct 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.
Question 2: When verifying benefits for a patient covered under a grandfathered health plan, which ACA-mandated benefit may NOT be required?
- Emergency services coverage
- Coverage of pre-existing conditions
- Preventive care with no cost-sharing (Correct answer)
- Mental health parity
Correct 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.
Question 3: 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?
- Proceed using the existing authorization number
- Obtain a new authorization for the updated facility (Correct answer)
- Cancel the order and reschedule at the original facility
- Bill under the authorization and appeal if denied
Correct 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.
Question 4: Which document should a Patient Access Representative request to verify that a commercial insurance plan has accepted assignment of benefits?
- Explanation of Benefits (EOB)
- Certificate of Coverage
- Assignment of Benefits form signed by the patient (Correct answer)
- Insurance ID card
Correct 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.
Question 5: An insurer's eligibility response shows 'coverage terminated.' The patient insists coverage is active. What is the best next step?
- Accept the patient as self-pay immediately
- Call the insurer's provider line to manually verify coverage (Correct answer)
- Deny service until the patient provides a new insurance card
- Submit a claim anyway and appeal the denial
Correct 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.
Question 6: What is the purpose of a 'Level of Care' determination in the prior authorization process for inpatient admissions?
- To confirm the patient's copay amount
- To determine whether the admission meets medical necessity criteria for the requested level (Correct answer)
- To assign an ICD-10 diagnosis code
- To verify the patient's out-of-pocket maximum
Correct 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.
Question 7: 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?
- Proceed with the visit and bill Medicaid fee-for-service instead
- Contact the PCP's office to obtain a same-day referral before providing non-emergency services (Correct answer)
- Waive the referral requirement as a one-time exception
- Collect full payment upfront and let the patient seek reimbursement
Correct 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.
PAR Insurance Verification & Authorization 2
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?