CMAA Insurance Verification and Processing 5 — Questions and Answers
Question 1: A patient's plan requires a 'referral' but the patient saw a specialist without one. The claim is denied. Which action best resolves this situation?
- Contact the primary care physician to obtain a retroactive referral if allowed by the plan (Correct answer)
- Resubmit the claim marked as an emergency visit
- Write off the balance and do not bill the patient
- File an appeal citing medical necessity without obtaining a referral
Correct answer: Contact the primary care physician to obtain a retroactive referral if allowed by the plan
Some plans allow retroactive referrals; contacting the PCP and the insurer to request one is the correct first step before pursuing other options.
Question 2: What is the purpose of a 'remittance advice' (RA) sent by an insurance payer?
- To explain how each claim was adjudicated, including payment amounts and denial reasons (Correct answer)
- To notify the patient of their out-of-pocket responsibility
- To authorize future procedures for a specific patient
- To list all providers credentialed with the payer
Correct answer: To explain how each claim was adjudicated, including payment amounts and denial reasons
A remittance advice is sent to the provider and details how each submitted claim was processed, including payments made and reasons for any adjustments or denials.
Question 3: A patient's insurance uses a 'usual, customary, and reasonable' (UCR) fee schedule. The provider charges $400, but the UCR for that service is $300. The plan pays 80% of UCR. How much does the insurer pay?
- $240 (Correct answer)
- $320
- $300
- $400
Correct answer: $240
The insurer pays 80% of the UCR ($300), which equals $240; the patient may be responsible for the remaining $60 plus any balance up to the provider's charge if the provider is out of network.
Question 4: A Coordination of Benefits (COB) calculation determines the primary plan pays $150 and the secondary plan's allowed amount would be $180 for the same service. Using the standard COB method, how much does the secondary plan pay?
- $30, covering the difference between the two allowed amounts (Correct answer)
- $180, paying its full allowed amount
- $150, matching the primary payment
- $0, because the primary already paid
Correct answer: $30, covering the difference between the two allowed amounts
Under standard COB, the secondary plan pays the difference between its allowed amount and what the primary already paid, so $180 − $150 = $30.
Question 5: Which of the following best describes an 'accumulator' in health insurance?
- A running total of amounts applied toward the deductible or out-of-pocket maximum during a benefit year (Correct answer)
- A list of approved providers within the network
- The process of accumulating prior authorization approvals
- A payer's method for tracking timely filing deadlines
Correct answer: A running total of amounts applied toward the deductible or out-of-pocket maximum during a benefit year
Accumulators track how much a patient has paid toward cost-sharing thresholds like the deductible and out-of-pocket maximum throughout the plan year.
Question 6: A patient states their employer-sponsored plan is self-funded. Which federal law primarily governs self-funded employer health plans rather than state insurance regulations?
- ERISA (Employee Retirement Income Security Act) (Correct answer)
- HIPAA (Health Insurance Portability and Accountability Act)
- ACA (Affordable Care Act)
- COBRA (Consolidated Omnibus Budget Reconciliation Act)
Correct answer: ERISA (Employee Retirement Income Security Act)
Self-funded employer plans are governed by ERISA, which preempts most state insurance laws, giving these plans significant flexibility in benefit design.
Question 7: During eligibility verification, you discover the patient's coverage was terminated two weeks ago due to non-payment of premiums. The patient claims they paid. What is the best next step?
- Advise the patient to contact their insurer to resolve the lapse and document the verification result in the patient's account (Correct answer)
- Proceed with the visit and submit the claim, assuming the insurer made an error
- Refuse to see the patient until coverage is confirmed active
- Bill the patient's secondary insurer as the primary payer
Correct answer: Advise the patient to contact their insurer to resolve the lapse and document the verification result in the patient's account
The correct action is to inform the patient of the coverage status, advise them to contact the insurer, and document the verification findings; the provider may choose to proceed at their discretion.
CMAA Insurance Verification and Processing 5
A patient's plan requires a 'referral' but the patient saw a specialist without one.
The claim is denied.
Which action best resolves this situation?