CMAA Insurance Verification and Processing 2 — Questions and Answers
Question 1: What is the primary purpose of verifying insurance eligibility before an appointment?
- To determine medical history
- To ensure the practice will receive payment (Correct answer)
- To schedule with the correct provider
- To assign a medical record number
Correct answer: To ensure the practice will receive payment
Eligibility verification confirms active coverage and that planned services will be covered, ensuring proper reimbursement.
Verification confirms active coverage, identifies payer/plan type, reveals coverage limitations, determines copay/deductible amounts, and checks for prior authorization needs. Without it, the practice risks providing uncovered services. Most practices verify 48-72 hours before appointments.
Question 2: What information is typically found on the back of an insurance card?
- Patient DOB and SSN
- Claims address and customer service phone number (Correct answer)
- Primary care physician name
- Copayment for all services
Correct answer: Claims address and customer service phone number
The back typically has the claims submission address, customer service number, and provider services phone for verification and claims.
The front shows member name, ID, group number, plan type, copay amounts, and effective date. The back contains claims mailing address, electronic payer ID, customer service number, provider services number, pharmacy benefits, and sometimes a website. CMAAs should copy both sides at every visit.
Question 3: A patient has both Medicare and employer commercial insurance. Which is typically primary?
- Medicare is always primary
- Commercial plan is primary if employer has 20+ employees (Correct answer)
- Patient chooses which is primary
- Plan with lower premium is primary
Correct answer: Commercial plan is primary if employer has 20+ employees
Under Medicare Secondary Payer rules, the employer plan is primary if the employer has 20+ employees for aged beneficiaries.
MSP rules: for working aged (65+) with employer plans covering 20+ employees, the employer plan is primary. Under 20 employees, Medicare is primary. Different thresholds apply for disability (100 employees) and ESRD (special 30-month period). Correct identification prevents claim denials.
Question 4: What does 'prior authorization' mean in insurance processing?
- Patient must pay before service
- Insurance must approve certain services before they are performed (Correct answer)
- Referring physician must write a letter
- Patient must sign a consent form
Correct answer: Insurance must approve certain services before they are performed
Prior authorization requires insurance company approval before performing certain services, procedures, or prescriptions.
Prior authorization determines medical necessity. Common services requiring it include advanced imaging, surgeries, specialty medications, and DME. CMAAs submit clinical documentation via phone, fax, or portal. Failure to obtain required authorization results in denial, leaving the patient or practice responsible.
Question 5: What is a referral in managed care insurance plans?
- A letter from the patient requesting a specialist
- An authorization from the PCP for the patient to see a specialist (Correct answer)
- A transfer of medical records
- An insurance company recommendation
Correct answer: An authorization from the PCP for the patient to see a specialist
In managed care, a referral is PCP authorization directing the patient to a specialist within the plan's network.
In HMOs, the PCP must provide a referral before specialist visits. Referrals specify the specialist, reason, and authorized visits. Without one, the visit may not be covered. PPOs generally don't require referrals. CMAAs must verify referral requirements and ensure they're on file.
Question 6: A patient has a $2,000 deductible and has met $1,500. The visit costs $200. How much applies to the deductible?
- $200 (Correct answer)
- $500
- $1,500
- $0
Correct answer: $200
With $500 remaining on the deductible, the full $200 visit applies since it's less than the remaining amount.
Deductible: $2,000. Already met: $1,500. Remaining: $500. Since $200 < $500 remaining, the full $200 applies to the deductible. Patient owes $200. After this visit, $300 remains on the deductible. Once fully met, insurance pays its share per the coinsurance rate.
CMAA Insurance Verification and Processing 2
What is the primary purpose of verifying insurance eligibility before an appointment?