PAR Insurance Verification Processes 3 — Questions and Answers
Question 1: Which government program provides health insurance specifically to individuals aged 65 and older, as well as certain younger individuals with disabilities?
- Medicaid
- CHIP
- Medicare (Correct answer)
- TRICARE
Correct 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.
Question 2: A patient has Medicare Part A and Part B. Which part covers physician office visits?
- Part A
- Part B (Correct answer)
- Both parts equally
- Neither; a supplemental plan is required
Correct answer: Part B
Medicare Part B covers outpatient services including physician office visits, while Part A covers inpatient hospital stays.
Question 3: When verifying a patient's TRICARE coverage, which unique piece of information is typically required that differs from commercial insurance verification?
- The patient's Social Security Number only
- The sponsor's military service branch and ID number (Correct answer)
- The patient's employer's name
- The patient's date of last hospitalization
Correct 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.
Question 4: 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?
- $500
- $600 (Correct answer)
- $900
- $1,000
Correct answer: $600
The patient applies the remaining $500 deductible first, then pays 20% coinsurance on the remaining $500 ($100), totaling $600.
Question 5: What does 'non-covered service' mean in the context of insurance verification?
- A service the patient refused
- A service excluded from coverage under the patient's plan benefits (Correct answer)
- A service provided by an out-of-network provider
- A service requiring a referral that was not obtained
Correct 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.
Question 6: 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?
- Proceed with the visit and hope the referral is obtained later
- Contact the patient's PCP to obtain the referral before or document the attempt before proceeding (Correct answer)
- Deny the service entirely
- Bill the visit as a new patient without referral documentation
Correct 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.
Question 7: Which of the following best describes 'real-time eligibility verification' (RTE)?
- Mailing an eligibility form to the insurer
- Electronically querying a payer's system to receive instant coverage information (Correct answer)
- Calling the insurer after services are rendered
- Reviewing last year's insurance documents on file
Correct 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.
PAR Insurance Verification Processes 3
Which government program provides health insurance specifically to individuals aged 65 and older, as well as certain younger individuals with disabilities?