PAR Insurance Verification & Authorization 2

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?

Accepted Answer

The plan held longest pays primary

Answer

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?

Accepted Answer

Preventive care with no cost-sharing

Answer

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?

Accepted Answer

Obtain a new authorization for the updated facility

Answer

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?

Accepted Answer

Assignment of Benefits form signed by the patient

Answer

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?

Accepted Answer

Call the insurer's provider line to manually verify coverage

Answer

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

(PAR) Patient Access Representative Certification Practice Test

(PAR) Patient Access Representative Certification Practice Test

PAR Insurance Verification & Authorization 2