Insurance Eligibility and Other Payer Requirements

Question 1

What is the Birthday Rule?

Answer 1

When the patient is a minor and has dual coverage from both parents, the parent whose birthday is first in the calendar year(don’t factor in the birth year) is the primary insurance. If the parents are divorced, the parent with custody or has the insurance longer will be primary.

Question 2

What do you need for a patient who’s a minor?

Answer 2

You will need the Guarantor or Policy holder information.

Question 3

What is a Guarantor?

Answer 3

The Guarantor holds financial responsibility for the patient’s health care bill.

Question 4

What is a Policy Holder?

Answer 4

This is the owner of the health insurance.

Question 5

What is an ABN?

Answer 5

It is an Advanced Beneficiary Notice. This is a form the patient must sign acknowledging Medicare might not cover the services they need. Must have reason the service is not covered.

Question 6

What is COB?

Answer 6

Coordination of Benefits. This means the patient has dual coverage and reported their insurances in the wrong order. Primary insurance is actually the secondary insurance and vice versa.

Question 7

What is an EMR?

Answer 7

It is an Electronic Medical Record used for one organization.

Question 8

What is an EHR?

Answer 8

This is an Electronic Health Record used for multiple organizations.

Question 9

What is a Premium?

Answer 9

What you pay monthly to keep your health insurance active.

Question 10

What is a Deductible?

Answer 10

This is the amount the patient is responsible for before the insurance plan pays a percentage of the Allowable amount. Deductibles renew every year.

Question 11

What is a Copay?

Answer 11

This is a fixed/set amount paid for each service. The insurance will pay the remaining allowable amount.

Question 12

What is a Coinsurance?

Answer 12

This is the percentage of costs of covered services after the deductible has been met.

Question 13

What is Care Credit?

Answer 13

This is a Credit Card that covers medical expenses. The provider will be paid in full and the patient will have a monthly statement like a normal credit card.

Question 14

What is an HSA?

Answer 14

This is a Health Savings Account. The employer deducts a set amount from each paycheck(untaxed) and places funds on a medical card at the beginning of the year. They can use it for any OOP expense like deductible, coins, copays….

Question 15

Why do you need Patient Registration?

Answer 15

This is when the patient fills out forms and the provider will receive all needed information in order to send a clean claim. This is where you get all patient demographics.

Question 16

What is EDI?

Answer 16

Electronic Data Interchange

Question 17

What is ED?

Answer 17

Emergency Department

Question 18

What is NAIC?

Answer 18

National Association of Insurance Commissioner

Question 19

What is Timely Filing?

Answer 19

It is when the organization is required to submit a claim to the insurance plan for services within an outlined time limit. If Timely Filing has passed, the provider is held liable.

Question 20

What is the first step to insurance verification?

Answer 20

It is to collect the patient’s insurance information and verify their identity with a photo ID.

Question 21

Why is verifying patient eligibility so important?

Answer 21

This identifies the primary payer and offers specific details about the patient’s coverage limits.

Question 22

How can you verify insurance eligibility?

Answer 22

Through the plan’s eligibility call line, an online portal, electronic data interchange(EDI), or in your EHR via an eligibility application.

Question 23

What information does the EDI lack when verifying eligibility?

Answer 23

It cannot provide remaining deductible amounts, coinsurance, or if authorization is required. You will have to contact the health care plan.

Question 24

When calling a health insurance plan, how will they identify the patient?

Answer 24

Using the Member ID number and the group number on their insurance card.

Question 25

What does it mean when a provider is in-network(INN)?

Answer 25

This is a provider who has signed an agreement with the insurance plan. They have established allowed amounts for each CPT code that the provider agrees to accept as payment in full.

Question 26

What does it mean when a provider is out-of-network(OON)?

Answer 26

This is a provider who does not have a signed agreement with an insurance plan. If the patient does not have OON benefits, they will have to be Self pay.

Question 27

Prior to scheduling, what should the specialist do?

Answer 27

Review patient benefits and verify that any utilization management requirements have been met. Like precertification or preauthorization.

Question 28

What are Covered Benefits?

Answer 28

They are services outlined in the policy that are payable by the health plan.

Question 29

What are Preventative Services?

Answer 29

These are offered to the policyholder with the intent to prevent or avoid health problems or injuries. Usually covered 100%, the deductible does not apply.

Question 30

What are Non-Covered Benefits?

Answer 30

These are services not deemed medically necessary like cosmetic surgery.

Question 31

What is an Out-Of-Pocket (OOP) Maximum?

Answer 31

This is the dollar amount required before full coverage begins.

Question 32

What happens if a required referral, preauthorization, or reauthorization is not obtained?

Answer 32

The claim will be denied and you cannot bill the patient.

Question 33

What are some Out-Of-Pocket Expenses the patient might have?

Answer 33

Copays, Coinsurances, Deductibles, and Non-Covered Services.

Question 34

When should you collect patient payments?

Answer 34

At the time of services to increase cash collection and support the revenue cycle.

Question 35

What is important when it comes to patient payments?

Answer 35

It is important to communicate the financial responsibility to the patient.

Question 36

What are patients who do not have insurance referred to as?

Answer 36

Self-pay or Private pay

Question 37

What is a Hardship Waiver?

Answer 37

It will reduce the amount the patient owes or eliminate it. The patient must show proof of hardship and Federal Poverty Level(FPL)

Question 38

What factors into a patient’s Hardship or FPL?

Answer 38

Cost of living, Income, Family Size, and the Extent of the Patient’s Medical Bills.

Question 39

What is a Tertiary Insurance?

Answer 39

This means the patient is covered by three insurance plans and this plan is billed last.

Question 40

What is a Primary Insurance?

Answer 40

This insurance will pay first and the EOB will be sent along with the Secondary Claim.

Question 41

What is Secondary Insurance?

Answer 41

Once the primary insurance pays, the secondary insurance will pay the remaining balance.