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Question 1Insurance Eligibility and Prior Authorization
What is the primary purpose of verifying a patient's insurance eligibility before a scheduled service?
- To calculate the practice's contractual write-off
- To confirm active coverage on the date of service Correct answer.
- To determine whether the service is medically necessary
- To assign the correct CPT code for the encounter
Explanation
Eligibility verification confirms that coverage is active on the date of service and identifies the correct payer, plan, and benefit level. Medical necessity review, code assignment, and contractual adjustments occur in separate processes.
Question 2Insurance Eligibility and Prior Authorization
What is prior authorization?
- A payer's review of a claim after the service is billed
- A payer's approval obtained before a service is rendered Correct answer.
- A provider's agreement to accept the contracted rate
- A patient's written consent for treatment
Explanation
Prior authorization, also called precertification, is a payer's prospective approval for a specific service obtained before care is delivered. It establishes in advance that the plan will consider the service covered.
Question 3Insurance Eligibility and Prior Authorization
After a payer approves a planned service, what should billing staff document in the patient's record?
- The referring provider's NPI taxonomy code
- The practice's fee schedule for the procedure
- The authorization number and approved date range Correct answer.
- The patient's employer name and hire date
Explanation
The authorization number and the approved dates must be documented so the claim can be matched to the approval. Missing or mismatched authorization data is a common cause of denials.
Question 4Insurance Eligibility and Prior Authorization
Under many HMO and managed care plans, what document authorizes a patient to see a specialist?
- A referral from the primary care provider Correct answer.
- An assignment of benefits
- A coordination of benefits form
- An advance beneficiary notice
Explanation
In HMO and other gatekeeper products, the primary care provider issues a referral before the patient sees a specialist. The referral number is often required on the claim in addition to any plan authorization.
Question 5Insurance Eligibility and Prior Authorization
A patient's MRI is performed, and the practice later learns the plan required prior authorization. What is the most likely consequence?
- The patient's eligibility is retroactively terminated
- The payer must pay because the service was rendered
- The claim is automatically forwarded to Medicare
- The claim may be denied for missing authorization Correct answer.
Explanation
When a plan requires prior authorization, a claim submitted without it is typically denied for missing authorization. The practice may request a retroactive review or file an appeal, but payment is not guaranteed.
Question 6Insurance Eligibility and Prior Authorization
A remittance advice shows claim adjustment reason code 197. What does this indicate?
- The claim was paid at the out-of-network benefit level
- The patient's coverage was terminated before the service date
- Precertification or authorization was absent on the claim Correct answer.
- The service is considered experimental by the payer
Explanation
CARC 197 is defined as precertification, authorization, or notification absent. It signals that a required approval was missing, so the practice must supply the authorization number or pursue an appeal.
Question 7Insurance Eligibility and Prior Authorization
Which term describes a payer's review of medical necessity for a service already provided, usually because authorization was not obtained in advance?
- Concurrent review
- Retrospective review Correct answer.
- Peer-to-peer review
- Prospective review
Explanation
Retrospective review evaluates medical necessity after the service has been delivered, often when advance authorization was missed. Concurrent review occurs during care and prospective review occurs before care.
Question 8Insurance Eligibility and Prior Authorization
The birthday rule determines which plan pays first when a dependent child is covered by both parents' plans. Under this rule, which plan is primary?
- The plan of the parent with the higher income
- The plan of the parent with the later birthday
- The plan that enrolled the child first
- The plan of the parent with the earlier birthday Correct answer.
Explanation
Under the birthday rule used in many commercial coordination of benefits provisions, the plan of the parent whose birthday falls earlier in the calendar year is primary for the dependent child.
Question 9Insurance Eligibility and Prior Authorization
A 68-year-old patient still works and is covered by her employer's group health plan, which has 25 employees. She also has Medicare. Which payer is primary for her services?
- Medicare, because it is always primary for beneficiaries over 65
- The group health plan of the current employer Correct answer.
- Medicare, because she is past age 65
- The plan with the earliest effective date of coverage
Explanation
Under the Medicare Secondary Payer working-aged provision, the group health plan of an employer with 20 or more employees pays first for a beneficiary age 65 or older who is covered through current employment.
Question 10Insurance Eligibility and Prior Authorization
Under coordination of benefits, what is Medicaid's general position when a patient also has commercial coverage?
- It shares the claim equally with the commercial plan
- Primary, because it is a federal-state program
- Payer of last resort after other coverage pays Correct answer.
- Primary for preventive services only
Explanation
Medicaid is generally the payer of last resort. It considers payment from other liable sources before paying and typically covers only remaining cost sharing.
Question 11Insurance Eligibility and Prior Authorization
In electronic data interchange, which transaction pair is used to request and receive eligibility and benefit information?
- 270 and 271 Correct answer.
- 278 and 278 response
- 276 and 277
- 837 and 835
Explanation
The 270 is the eligibility benefit inquiry and the 271 is the eligibility benefit response. These transactions let staff confirm coverage electronically before the visit.
Question 12Insurance Eligibility and Prior Authorization
Which statement best reflects prior authorization requirements for emergency services under most commercial and government plans?
- Emergency services generally are not subject to prior authorization Correct answer.
- Emergency care always needs an authorization number on the claim
- Authorization must be obtained within 24 hours before arrival
- Authorization is required only when the patient is admitted
Explanation
Plans generally may not require prior authorization for emergency services, consistent with prudent-layperson standards. Notification or authorization may be required for a resulting inpatient admission, but not for the emergency care itself.
Question 13Insurance Eligibility and Prior Authorization
Where does a practice typically find the list of services that require prior authorization for a specific plan?
- The payer's provider manual or authorization list Correct answer.
- The patient's explanation of benefits
- The appendix of the CPT codebook
- The practice's internal charge master
Explanation
Payers publish the services and codes requiring prior authorization in provider manuals and on their websites, and update these lists periodically. Checking the current list prevents avoidable denials.
Question 14Insurance Eligibility and Prior Authorization
A Medicare beneficiary is to receive a service the practice believes Medicare may not cover as medically necessary. Which notice allows the practice to bill the patient if the claim is denied?
- A Notice of Privacy Practices
- An Advance Beneficiary Notice of Noncoverage Correct answer.
- A coordination of benefits questionnaire
- An assignment of benefits form
Explanation
An ABN explains that Medicare may not pay for an item or service and, when properly issued and signed, shifts financial liability to the beneficiary if the claim is denied. It does not obtain coverage or authorization.
Question 15Insurance Eligibility and Prior Authorization
A patient enrolled in a Medicaid managed care plan presents for a non-emergency visit. Which item should be verified along with eligibility?
- Whether the patient signed a billing consent
- The employer's plan year end date
- The PCP assigned by the managed care plan Correct answer.
- Whether the patient has a supplemental Medicare policy
Explanation
Medicaid managed care members are assigned to a specific plan and primary care provider. Confirming the plan and PCP ensures the visit is covered and that referral rules are followed.
Question 16Insurance Eligibility and Prior Authorization
Which information is typically found on a patient's insurance identification card?
- The member ID number and group number Correct answer.
- The practice's contracted fee schedule
- The patient's complete medical history
- The number of the patient's prior claims
Explanation
Identification cards typically show the member ID, group number, plan type, and payer contact or electronic payer ID used for eligibility inquiries. Clinical and fee information is not printed on the card.
Question 17Insurance Eligibility and Prior Authorization
A payer authorizes four physical therapy visits. The patient has received four visits and the provider recommends two more. What should the practice do?
- Change the dates of service on the original approval
- Request an extension or additional authorization first Correct answer.
- Submit the extra visits as self-pay without notice
- Bill the extra visits under the original approval
Explanation
An authorization is limited to the units or visits approved. Additional services require an extension or a new authorization before they are rendered to avoid a denial.
Question 18Insurance Eligibility and Prior Authorization
Which of the following is an example of a service that commonly requires prior authorization?
- A same-day sick visit for a sore throat
- An elective inpatient surgical procedure Correct answer.
- A routine blood pressure check at an office visit
- An over-the-counter medication bought by the patient
Explanation
Non-emergency, high-cost services such as elective inpatient surgery commonly appear on prior authorization lists. Routine office visits and items the patient buys directly generally do not.
Question 19Insurance Eligibility and Prior Authorization
An employee is injured at work and the injury is accepted as work related. Which coverage is generally primary for the treatment?
- The employee's Medicare Advantage plan
- The employee's auto medical payments coverage
- The workers' compensation carrier Correct answer.
- The employee's group health plan
Explanation
When an injury is accepted as work related, the workers' compensation carrier is primary. Group health plans generally exclude or pay secondary to workers' compensation for such injuries.
Question 20Insurance Eligibility and Prior Authorization
A payer authorizes a procedure for a specific CPT code and date range, but the surgeon performs a different, more extensive procedure. What is the most accurate statement?
- The original authorization covers any procedure by the same surgeon
- A new authorization is needed for the procedure that differs from the approved one Correct answer.
- The claim is payable because an authorization number is present
- Only the patient's consent is needed for the change in procedure
Explanation
An authorization is issued for specific procedures, diagnoses, and dates of service. When the performed procedure differs materially from what was approved, a new authorization is required to avoid denial.
Question 21Insurance Eligibility and Prior Authorization
Which term refers to a payer's approval process completed before an inpatient admission or procedure?
- Claim adjudication
- Provider credentialing
- Post-payment audit
- Precertification Correct answer.
Explanation
Precertification is the payer's prospective review and approval before an admission or procedure is performed. It is often used interchangeably with prior authorization.
Question 22Insurance Eligibility and Prior Authorization
A payer's reviewer denies an authorization request. What is a peer-to-peer review?
- An appeal decided by an independent state agency
- A re-audit of previously paid claims by the payer
- A discussion between the payer's reviewer and the provider Correct answer.
- A review of coverage history by billing staff
Explanation
A peer-to-peer review is a clinical discussion between the payer's physician reviewer and the treating provider to reconsider a denial. It often occurs before a formal written appeal is filed.
Question 23Insurance Eligibility and Prior Authorization
The day after a visit, a payer notifies the practice that the patient's coverage ended the previous month. What is the practice's likely next step?
- Contact the patient about other coverage or self-pay Correct answer.
- Resubmit the claim with a different date of service
- Bill Medicare as a secondary payer automatically
- Write off the balance as a contractual adjustment
Explanation
A retroactive termination means the patient had no coverage on the date of service, so the claim will deny. The practice should look for other coverage and, following notice rules, discuss payment responsibility with the patient.
Question 24Insurance Eligibility and Prior Authorization
A patient with an HMO plan sees a specialist who is outside the network without any referral. What is the likely outcome?
- The plan automatically converts to a PPO benefit
- The specialist must accept the plan's contracted rate
- The claim pays at the in-network benefit level
- The service may be denied or paid at a reduced rate Correct answer.
Explanation
HMO benefits apply to in-network care arranged through the primary care provider. Care obtained outside the network without approval is commonly denied or paid at a reduced out-of-network rate.
Question 25Insurance Eligibility and Prior Authorization
What is the purpose of asking a patient to complete a coordination of benefits questionnaire?
- To verify the patient's photo identification
- To document an advance beneficiary notice
- To obtain the patient's consent for treatment
- To identify other coverage that may pay the claim Correct answer.
Explanation
A coordination of benefits questionnaire gathers information about other plans so claims can be billed to primary and secondary payers in the correct order. Accurate COB data prevents denials and overpayment recovery.
Question 26Insurance Eligibility and Prior Authorization
In a managed care plan, how does a referral differ from a prior authorization?
- A referral applies only to inpatient hospital care, while prior authorization applies only to outpatient office visits and procedures
- A referral is issued by the payer to authorize payment, while prior authorization is issued by the specialist who will perform the service
- A referral guarantees that a service will be paid, while prior authorization confirms only that the provider is in the payer's network
- A referral directs a patient to a specialist, while prior authorization is a payer's approval of coverage for a service Correct answer.
Explanation
A referral is a care-coordination tool: the primary care provider directs the patient to a specialist. Prior authorization is a utilization management process in which the payer reviews and approves coverage for a specific service before it is delivered. In an HMO a specialty visit may require both a referral and, for certain services, a prior authorization.
Question 27Insurance Eligibility and Prior Authorization
A patient's plan has a $1,500 annual deductible, of which $1,200 has already been met, and 20% coinsurance after the deductible is satisfied. The patient receives a covered in-network service with an allowed amount of $800. What is the patient's out-of-pocket responsibility for this service?
- $300
- $400 Correct answer.
- $160
- $800
Explanation
The patient first pays the remaining $300 of the deductible, leaving $500 of the allowed amount subject to coinsurance. Twenty percent of $500 is $100, so the total patient responsibility is $300 plus $100, or $400. The plan pays the remaining $400.
Question 28Insurance Eligibility and Prior Authorization
Which ASC X12N transaction is used to request and respond to a health care services review, such as a prior authorization?
- 278 health care services review Correct answer.
- 837 health care claim
- 270 eligibility benefit inquiry
- 835 health care payment and remittance advice
Explanation
The 278 transaction is the standard electronic format for health care services review, carrying authorization requests and the payer's certification or denial response. The 837 transmits claims, the 835 transmits payment and remittance information, and the 270/271 pair handles eligibility inquiries and responses.
Question 29Insurance Eligibility and Prior Authorization
A payer issues a prior authorization valid from March 1 through May 31. The patient schedules the approved surgery for June 14. What is the most appropriate action?
- Submit the claim with the original authorization, because payers allow a 30-day grace period after expiration
- Request an extension or a new authorization before the June 14 date of service Correct answer.
- Ask the surgeon to substitute a procedure code that does not require authorization
- Collect the entire procedure charge from the patient before the surgery is performed
Explanation
An authorization is a time-limited approval; a service performed outside the approved date range is treated as unauthorized and is likely to be denied. The practice should contact the payer for an extension or a new authorization covering June 14 before the service is delivered. Changing the code or pre-collecting the full charge does not resolve the coverage gap.
Question 30Insurance Eligibility and Prior Authorization
A patient is approved for Medicaid with coverage retroactive three months. The practice has an unpaid self-pay balance from an office visit two months ago. What is the most appropriate next step?
- Bill Medicare instead, because Medicaid is prohibited from paying for prior dates of service
- Confirm the retroactive dates, bill Medicaid, and refund patient payments collected Correct answer.
- Write off the balance, because Medicaid never covers services provided before the approval date
- Hold the claim until the patient's next Medicaid redetermination period begins
Explanation
Many Medicaid programs grant coverage retroactively for a limited period before the approval month. The practice should verify the exact retroactive dates, submit claims for covered dates of service, and return any payments the patient made for those dates.
Question 31Insurance Eligibility and Prior Authorization
When verifying eligibility for a new patient, which item confirms that the practice will be paid as an in-network provider?
- The member's group number printed on the card
- The provider's participation status with that plan Correct answer.
- The copay amount listed on the card
- The patient's date of birth, address, and phone number on file
Explanation
Network status is determined by whether the individual provider or group holds a participating agreement with that specific plan product. Confirming participation protects the patient from balance billing and determines the contracted reimbursement rate. Group numbers and copay amounts describe the member's benefits, not the provider's network standing.
Question 32Insurance Eligibility and Prior Authorization
Under Medicare Advantage rules, an expedited (urgent) prior authorization request must be decided no later than how long after the plan receives it?
- Within 7 calendar days
- Within 14 calendar days
- Within 72 hours Correct answer.
- Within 30 calendar days
Explanation
CMS requires Medicare Advantage organizations to decide expedited requests as quickly as the enrollee's condition requires, and no later than 72 hours after receipt. Standard (non-urgent) requests must be decided no later than 14 calendar days. The shorter timeframe exists to protect access to urgently needed care.
Question 33Insurance Eligibility and Prior Authorization
Under the Affordable Care Act, in-network preventive services recommended by the USPSTF must generally be covered in what way by non-grandfathered plans?
- With no cost sharing for the patient Correct answer.
- Only after the annual deductible has been fully satisfied
- At 50 percent coinsurance after the visit
- Only for patients who are 50 years of age or older
Explanation
Non-grandfathered plans must cover recommended in-network preventive services without deductibles, copayments, or coinsurance. Cost sharing may still apply when the same service is billed with a diagnosis that makes it diagnostic rather than preventive. Age-related recommendations apply to specific services, not to preventive coverage as a whole.
Question 34Insurance Eligibility and Prior Authorization
A plan requires documented failure of a preferred, lower-cost medication before it will approve a non-preferred specialty drug. What is this requirement called?
- Prior authorization
- Step therapy Correct answer.
- Therapeutic interchange
- Quantity limit
Explanation
Step therapy, sometimes called a fail-first requirement, requires the patient to try preferred agents and document an inadequate response before a more costly drug is covered. The required trial is usually documented as part of a prior authorization request. Quantity limits restrict how much of a drug is covered, and therapeutic interchange substitutes one drug for another.
Question 35Insurance Eligibility and Prior Authorization
A large employer sponsors a self-funded health plan governed by ERISA. Which statement about state insurance mandates and this plan is accurate?
- They must adopt Medicaid prior authorization rules for all covered services
- They must follow every state mandate in states where employees live
- They are prohibited from requiring prior authorization for any service
- They are generally exempt from state insurance mandates and follow the plan document Correct answer.
Explanation
Self-funded ERISA plans generally preempt state insurance laws, so benefits and utilization management rules are set by the plan document rather than by state mandates. That is why benefit language and prior authorization lists can differ from a state-regulated fully insured product. Federal requirements, such as those for preventive services, still apply.
Question 36Insurance Eligibility and Prior Authorization
A practice performs a service that appeared on the payer's prior authorization list but never obtained the authorization. The claim denies for no authorization on file. What is the most appropriate first step?
- Check whether the plan allows retroactive authorization or an appeal for the missed requirement Correct answer.
- Resubmit the same claim to a different payer to obtain payment
- Bill the patient the full charge immediately without any prior notice
- Appeal the denial as a billing error and resubmit the claim with modifier 25
Explanation
Some plans permit retroactive authorization requests or accept an appeal with clinical documentation showing medical necessity when authorization was missed. The practice should first confirm what the specific plan allows rather than assuming the denial is final. Billing the patient without notice or resubmitting to another payer can create compliance problems.
Question 37Insurance Eligibility and Prior Authorization
Which statement best describes what payers mean by medical necessity?
- Care that falls within the plan's annual benefit maximum and remaining deductible
- Care that is clinically appropriate and consistent with accepted standards Correct answer.
- Care delivered at whichever facility offers the lowest contracted rate for the service
- Any service that the patient requests from a licensed provider in the network
Explanation
Medical necessity refers to care that is clinically appropriate for the patient's condition and consistent with generally accepted standards of practice. It is the central question in prior authorization and utilization review. Benefit maximums and cost sharing determine how much the plan pays, not whether care is necessary.
Question 38Insurance Eligibility and Prior Authorization
A patient injured in a motor vehicle accident has personal injury protection (PIP) coverage through an auto policy and also carries a commercial health plan. Which payer is generally primary for the related medical bills?
- Medicare, if the patient is also enrolled in Medicare
- The auto insurer's personal injury protection coverage, subject to state law Correct answer.
- The health plan, because group health coverage always pays first
- The patient, who must pay the provider and then seek reimbursement
Explanation
When an injury arises from an auto accident and no-fault or personal injury protection coverage applies, that auto coverage is generally primary and the health plan pays secondarily. The exact order can vary with the policy and state requirements, which is why accident-related questions are asked at intake. Billing the auto carrier correctly prevents later recoupment from the health plan.
Question 39Insurance Eligibility and Prior Authorization
A payer's prior authorization list requires approval when a procedure is performed in a hospital outpatient department but not when the identical procedure is performed in a freestanding office. Which concept does this illustrate?
- Coordination of benefits between two health plans
- Retrospective review of a claim after payment
- Global surgical package and multiple procedure reduction rules
- Site-of-service-specific prior authorization requirements Correct answer.
Explanation
Payers increasingly tie authorization requirements to the place where a service is delivered, because reimbursement and utilization differ between hospital outpatient departments and freestanding offices. The same procedure code may therefore need approval in one setting and not another. The practice must confirm both the code and the planned site of service when checking authorization lists.
Question 40Insurance Eligibility and Prior Authorization
On the third day of an inpatient stay, a payer's utilization review nurse contacts the hospital to evaluate whether continued hospitalization is medically necessary. This activity is best described as which type of review?
- Second-level appeal
- Prospective review
- Concurrent review Correct answer.
- Retrospective review
Explanation
Concurrent review occurs while the patient is still receiving care, allowing the payer to certify additional days or recommend discharge planning in real time. Prospective review happens before the service, and retrospective review happens after it. A second-level appeal is a formal reconsideration after an adverse determination.
Question 41Coding (Diagnosis and Procedure)
What is the maximum number of characters in a complete ICD-10-CM diagnosis code?
- Six
- Five
- Eight
- Seven Correct answer.
Explanation
ICD-10-CM codes are alphanumeric and begin with a letter; a code can be up to seven characters long. A code is only complete when every required character, including a seventh character when the category requires one, has been assigned.
Question 42Coding (Diagnosis and Procedure)
What is the purpose of the ICD-10-CM Alphabetic Index?
- It assigns the final code that is reported on the submitted claim.
- It lists terms with candidate codes to verify in the Tabular List. Correct answer.
- It contains the official guidelines and conventions for coding.
- It lists procedure codes used for inpatient reporting.
Explanation
The Alphabetic Index is a lookup tool organized by diagnostic term; it points to a candidate code or category. The coder must then confirm the code in the Tabular List, where conventions such as notes and seventh characters determine the complete code.
Question 43Coding (Diagnosis and Procedure)
In ICD-10-CM, what does laterality identify?
- Which side of the body the condition affects Correct answer.
- The stage or severity of a malignant neoplasm
- Whether the condition is described as acute or chronic
- The order in which the diagnoses are listed on the claim
Explanation
Laterality characters specify the right or left side (and sometimes a bilateral designation) for conditions affecting paired organs or limbs. When laterality is documented, the specific laterality character must be assigned rather than an unspecified code.
Question 44Coding (Diagnosis and Procedure)
How many characters are in a HCPCS Level II code, and what is the first character?
- Six characters, beginning with a number
- Four characters, all numeric
- Five characters, beginning with a letter Correct answer.
- Five characters, all numeric
Explanation
HCPCS Level II codes consist of five characters; the first character is a letter, usually indicating the section (for example, J for drugs, E for durable medical equipment). The remaining characters may be letters or numbers.
Question 45Coding (Diagnosis and Procedure)
Which ICD-10-CM chapter contains codes for factors influencing health status and contact with health services?
- A00–B99
- S00–T88
- R00–R99
- Z00–Z99 Correct answer.
Explanation
Codes in the Z chapter are used when a patient encounters the health care system for a reason other than a current disease or injury, such as screenings, history codes, and status codes. They document circumstances rather than an active illness.
Question 46Coding (Diagnosis and Procedure)
Which code set is used to report inpatient hospital procedures on a UB-04 claim?
- ICD-10-PCS Correct answer.
- ICD-10-CM
- HCPCS Level II
- CPT
Explanation
ICD-10-PCS is the procedure classification system used for inpatient hospital reporting in the United States. CPT and HCPCS Level II are used for outpatient and physician procedure reporting.
Question 47Coding (Diagnosis and Procedure)
What is the purpose of CPT Category II codes?
- To track performance measures and quality data Correct answer.
- To report emerging technology procedures
- To report supplies and durable medical equipment
- To report services not described by a Category I code
Explanation
Category II codes are optional supplemental tracking codes made up of four digits followed by the letter F. They support performance measurement and quality reporting rather than describing a billable procedure.
Question 48Coding (Diagnosis and Procedure)
Which modifier indicates that a procedure was performed bilaterally?
- 50 Correct answer.
- LT
- RT
- 51
Explanation
Modifier 50 identifies a bilateral procedure performed on both sides of the body during the same operative session where the code is not already designated as bilateral. LT and RT identify one side only.
Question 49Coding (Diagnosis and Procedure)
In ICD-10-CM, what does an Excludes1 note indicate?
- The conditions can never be reported together. Correct answer.
- The excluded code may be reported as an additional code when documented.
- The condition is not payable by the payer.
- The excluded codes must be sequenced after the main diagnosis code.
Explanation
An Excludes1 note means the excluded codes cannot be assigned with the code carrying the note because the two conditions cannot occur together. When a condition is excluded in this way, the appropriate code is assigned from the excluded entry instead.
Question 50Coding (Diagnosis and Procedure)
A code note reads 'Code also any associated condition.' What does this instruction require?
- The note replaces the need for a combination code
- The secondary condition is optional and reported only if it affects treatment
- An additional code must be assigned to fully describe the condition Correct answer.
- The condition should be reported only when it is the first-listed diagnosis
Explanation
A 'code also' note directs the coder to assign an additional code to completely describe the patient's condition. The sequencing of the additional code depends on the circumstances of the encounter and any related instructional notes.