PAR Insurance Verification Processes 2 — Questions and Answers
Question 1: A patient presents with two insurance plans. Which coordination of benefits rule determines which plan pays first?
- The plan with the highest deductible pays first
- The patient's employer plan is always primary
- The birthday rule applies when a patient is covered under both parents' plans (Correct answer)
- The most recently obtained plan is always primary
Correct answer: The birthday rule applies when a patient is covered under both parents' plans
The birthday rule states that the parent whose birthday falls earliest in the calendar year has the primary insurance plan for dependent children.
Question 2: When verifying insurance for an outpatient surgical procedure, which information is MOST critical to confirm beyond basic eligibility?
- The patient's primary care physician name
- Whether prior authorization is required for the specific procedure code (Correct answer)
- The insurance company's mailing address
- The patient's co-pay for office visits
Correct answer: Whether prior authorization is required for the specific procedure code
Prior authorization requirements for surgical procedures must be confirmed before the procedure to avoid claim denial.
Question 3: A patient's insurance card shows 'OON' benefits. What does this indicate?
- The plan has no out-of-network coverage
- The plan offers out-of-network benefits with different cost-sharing (Correct answer)
- The patient is overdue on premiums
- The plan requires online-only authorization
Correct answer: The plan offers out-of-network benefits with different cost-sharing
OON stands for out-of-network, indicating the plan provides some coverage when using providers outside the preferred network, typically at higher cost-sharing.
Question 4: During verification, you discover a patient's Medicaid coverage was terminated last month. What is the FIRST action to take?
- Proceed with the visit and bill Medicaid anyway
- Inform the patient of the lapse and explore coverage options before services are rendered (Correct answer)
- Reschedule the appointment for next month
- Bill the visit as self-pay without notifying the patient
Correct answer: Inform the patient of the lapse and explore coverage options before services are rendered
The patient must be informed of the coverage lapse so they can make informed decisions about proceeding with care and payment options.
Question 5: Which term describes the fixed dollar amount a patient pays for a covered service, regardless of the total charge?
- Coinsurance
- Deductible
- Copayment (Correct answer)
- Premium
Correct answer: Copayment
A copayment (copay) is a predetermined fixed fee the patient pays at the time of service, separate from deductibles and coinsurance.
Question 6: A PAR receives a fax verification from an insurer listing 'active' status but with an effective date two weeks in the future. How should this be handled?
- Accept the verification as valid since it shows active
- Inform the patient their coverage is not yet effective and discuss financial responsibility (Correct answer)
- Re-verify in one week automatically
- Treat the patient as fully insured immediately
Correct answer: Inform the patient their coverage is not yet effective and discuss financial responsibility
Insurance coverage is only valid on or after the effective date, so services rendered before that date will not be covered.
Question 7: What is the primary purpose of obtaining a Reference Number during a phone-based insurance verification?
- To charge the patient a verification fee
- To document the call for auditing and dispute purposes if the claim is later denied (Correct answer)
- To speed up claim submission
- To verify the representative's identity
Correct answer: To document the call for auditing and dispute purposes if the claim is later denied
Reference numbers provide proof of the verification call and the information provided, which is essential if the payer later denies a claim that was verified as covered.
PAR Insurance Verification Processes 2
A patient presents with two insurance plans.
Which coordination of benefits rule determines which plan pays first?