VERIFYING INSURANCE ELIGIBILITY & BENEFITS Flashcards

1
Q

the 1st step to insurance verification

A

o Collect the patient insurance information
o Verify their identity with a photo ID

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2
Q

2nd step of verifying insurance elg & ben :
Determine what coverage the patient has according to the specific plan.

A

o Understanding how the plan pays
o What the patient responsibility (copay, deductible, coinsurance)

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3
Q

this plays a critic role in the revenue cycle…

A

Verification

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4
Q

What is the dedicated eligibility line?

A

verification can be done by calling this line if there are no other options

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5
Q

it is a provider that has signed a contract with the payer to accept assignment for services rendered…

A

In-network provider

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6
Q

it is what the payers have established for ea CPT that providers agree to accept as payment in full when contracted as in-network providers

A

allowed amount

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7
Q

it’s a provider that has not accepted assignment w an insurance company & pt will pay higher out-of-pocket expenses

A

Out-of-network provider

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8
Q

it determines which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan

A

Coordination of Benefits (COB)

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9
Q

this helps to minimize delay reimbursement or denied claims…

A

Insurance Verification

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10
Q

What is a bday rule?

A

it is when a child has coverage under both parents
it is determine by the (1) earliest month of the parent’s bday, (2) day as well, then (3) effective the longest

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11
Q

it is the monthly amount the policyholder pays to receive plan benefits…

A

Insurance Premium

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12
Q

it is the annual amount the policyholder must pay before the insurance plan will begin to pay for benefits

A

Deductible

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13
Q

When does the insurance start paying for the covered benefits?

A

when the deductible has been met by the policyholder

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14
Q

these are services offered to the policyholder with the intent to prevent or avoid health problems or injury

A

Preventive Services

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15
Q

it is a set amount that is paid for visits at the time of visit

A

Copayments

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16
Q

the percentage the insurance and patient will pay after the deductible has been met…

A

Coinsurance

17
Q

it is the dollar amount required before full coverage begins

A

Out-of-pocket maximum (OOPM)

18
Q

this must be paid to keep insurance active…

A

Premium

19
Q

are organized to contain and reduce medical costs and monitor the higher-cost services

A

Managed care programs

20
Q

a policy that requires the patient to be assigned to a designated PCP (Gatekeeper) Primary Care Physician

A

Health Maintenance Organization (HMO)