Insurance Verification and Processing Flashcards
7 cards from real CMAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Insurance Verification and Processing flashcards as text
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?
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.
What is the purpose of a 'remittance advice' (RA) sent by an insurance payer?
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.
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?
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.
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?
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.
Which of the following best describes an 'accumulator' in health insurance?
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.
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?
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.
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?
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.