Module 2: Insurance Eligibility and Other Payer Requirements

Question 1

What is the first step in insurance verification?

Answer 1

Collect patient insurance information and verify their identity with a photo ID

Question 2

What does insurance eligibility verification identify?

Answer 2

The primary payer for services and specific details about the patient’s coverage limits

Question 3

Name two methods for performing insurance eligibility verification

Answer 3

• Online portal
• Electronic data interchange (EDI)
• Directly within the EHR

Question 4

What is the purpose of the EDI system in insurance eligibility verification?

Answer 4

To automatically report eligible patients to the provider daily

Question 5

What is an in-network provider?

Answer 5

A provider that has signed a contract with the payer to accept assignment for services rendered

Question 6

True or False: An out-of-network provider typically results in lower out-of-pocket expenses for the patient.

Answer 6

False

Question 7

What is a deductible in insurance terms?

Answer 7

The annual amount the policyholder must meet before the insurance plan begins to pay for benefits

Question 8

What are covered benefits in an insurance plan?

Answer 8

• Visits to primary care providers
• Diagnostic and laboratory testing
• Preventive services

Question 9

Fill in the blank: Copayments are a set amount paid for _______.

Answer 9

[office visits, specialists, and ED visits]

Question 10

What does coinsurance represent in an insurance plan?

Answer 10

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

Question 11

What is the out-of-pocket maximum?

Answer 11

The dollar amount required before full coverage begins

Question 12

What is the birthday rule in coordination of benefits?

Answer 12

The caretaker with the earliest birthday in the calendar year is the primary plan

Question 13

What is timely filing in the context of insurance claims?

Answer 13

The requirement to submit a claim to the insurance plan within a specified time frame

Question 14

What is the filing limit for Medicare and TRICARE?

Answer 14

1 year from the date services were rendered

Question 15

What should be done if a preauthorization is not approved?

Answer 15

The specialist can file an appeal and provide additional patient history to support medical necessity

Question 16

What is the role of coordination of benefits (COB)?

Answer 16

To define the order of responsibility for claims when there is more than one payer

Question 17

What happens if a preauthorization is not obtained prior to a service being performed?

Answer 17

The claim may be denied

Question 18

List three financial responsibilities that organizations must discuss with patients.

Answer 18

• Deductible
• Copay
• Coinsurance

Question 19

True or False: Noncovered expenses are the financial responsibility of the insurance company.

Answer 19

False

Question 20

What is the purpose of reliable resources in billing and coding?

Answer 20

To provide accurate guidance and support for billing and coding practices

Question 21

What is the typical copay amount for a primary care provider office visit?

Answer 21

$25

Question 22

What is an example of a service that might require preauthorization?

Answer 22

• Diagnostic tests
• Emergency admissions
• Outpatient services needing inpatient setting

Question 23

What should be documented for Workers’ Compensation claims?

Answer 23

• Adjustor’s name
• Authorization number
• Date of injury or loss

Question 24

What is the significance of an insurance card?

Answer 24

It contains customer service contact information, utilization management contact information, and claims mailing address

Question 25

What is the maximum penalty for late claims submission in California Medicaid?

Answer 25

50% reduction for claims received after 10-12 months

Question 26

Fill in the blank: The insurance premium is the _______ paid each month to receive plan benefits.

Answer 26

[monthly amount]

Question 27

What type of organization requires a designated primary care physician (PCP)?

Answer 27

Health Maintenance Organization (HMO)

Question 28

What is the role of Medicare's crossover claims feature?

Answer 28

To expedite processing of claims that have more than one payer

Question 29

What can organizations do to increase cash collections for outstanding balances?

Answer 29

Collect out-of-pocket expenses at the time of service

Question 30

What is an example of a resource for billing and coding guidance?

Answer 30

Medicare Learning Network (MLN) Matters articles

Question 31

What should organizations do if they have questions about coding and billing?

Answer 31

Refer to reliable resources specific to their area of expertise

Question 32

What is the importance of understanding deductibles, coinsurance, and out-of-pocket costs?

Answer 32

It helps both the healthcare organization and the patient

Question 33

What is the cost of a knee replacement?

Answer 33

$5,000

Question 34

What is the deductible amount for the patient's plan?

Answer 34

$1,500

Question 35

How much of the deductible has been met by the patient this year?

Answer 35

$1,000

Question 36

What is the coinsurance policy of the patient's insurance?

Answer 36

80/20

Question 37

How much will the patient owe after the deductible is met for the knee replacement?

Answer 37

$1,400 ## Footnote This is calculated by adding the remaining deductible ($500) and the 20% coinsurance amount ($900).

Question 38

What are self-pay patients?

Answer 38

Patients who do not have insurance and are financially responsible for the cost of services rendered.

Question 39

What is a hardship waiver?

Answer 39

A waiver that reduces or eliminates the amount a patient owes due to financial burden.

Question 40

What must a patient provide to qualify for a hardship waiver?

Answer 40

Proof of qualification based on the federal poverty level.

Question 41

What factors can determine a patient's financial need?

Answer 41

* Cost of local living * Patient’s income, assets, and expenses * Patient’s family size * Scope and extent of patient’s medical bills

Question 42

What is the role of verification of benefits in managing accounts receivable?

Answer 42

It plays an important role in determining patient responsibility before calculating coinsurance.

Question 43

What are the payment methods accepted for medical services?

Answer 43

* Cash * Check * Credit card

Question 44

What is a medical credit card?

Answer 44

A credit card that allows patients to pay for medical services and repay the balance monthly.

Question 45

What is a Health Savings Account (HSA)?

Answer 45

An employee benefit account for medical expenses that is tax-exempt.

Question 46

What is capitation in terms of HMO plans?

Answer 46

A reimbursement method where providers are paid a fixed amount per patient, regardless of the number of visits.

Question 47

What is the purpose of the Advance Beneficiary Notice of Noncoverage (ABN)?

Answer 47

To document the beneficiary’s decision about a service that Medicare may not cover and transfer responsibility to the patient.

Question 48

What does the -GA modifier indicate?

Answer 48

Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case.

Question 49

What does the -GX modifier indicate?

Answer 49

Notice of Liability Issued, Voluntary Under Payer Policy.

Question 50

What does the -GY modifier indicate?

Answer 50

Notice of Liability Not Issued, Not Required Under Payer Policy.

Question 51

What does the -GZ modifier indicate?

Answer 51

Expect Item or Service Denied as Not Reasonable and Necessary.

Question 52

What are the four parts of Medicare?

Answer 52

* Part A: Inpatient services * Part B: Provider and outpatient services * Part C: Medicare Advantage plans * Part D: Prescription medication benefit

Question 53

What is dual eligibility in Medicare?

Answer 53

A program that assists qualified individuals with low income with premiums, copayments, coinsurance, and deductibles.

Question 54

What is Medigap?

Answer 54

A supplemental policy to Medicare offered by private insurance companies to cover costs not covered by traditional Medicare.

Question 55

What is TRICARE?

Answer 55

A government program for active military and their families, covering medical expenses, special programs, prescriptions, and dental services.

Question 56

What is the role of the Centers for Medicare and Medicaid Services (CMS)?

Answer 56

Oversees the operations of Medicare and selects Medicare Administrative Contractors (MAC) for claims processing.