Insurance and payer requirements
Insurance and payer requirements
This domain tests whether a claim meets payer rules before it is submitted: eligibility, benefits, coordination of benefits, authorization, medical necessity, timely filing, and clean-claim data. Items often describe a payer scenario and ask which verification or documentation step prevents the denial.
Rules and concepts
- Verify eligibility at registration and again before high-cost or scheduled services: active coverage, effective and termination dates, network status, PCP assignment, benefit limits, deductible, and out-of-pocket maximum.
- Coordination of benefits determines order. For dependent children, the birthday rule generally makes the parent whose birthday falls earlier in the year primary. Medicare Secondary Payer rules can make an employer group health plan primary for a working-aged beneficiary when the employer has 20 or more employees and coverage is based on current employment.
- Prior authorization or referral must be obtained when the payer requires it; emergency exceptions and retro-authorization rules are payer-specific. Record the authorization number and approved units.
- Medical necessity links the diagnosis to the service. Medicare may apply national or local coverage determinations; a noncovered service may require an ABN before the patient is billed.
- Timely filing is payer-specific and may run from the date of service or from the primary payer's remittance. A clean claim must carry the correct NPI, TIN, place of service, diagnosis pointers, units, and other payer-required fields.
Worked example
A 67-year-old Medicare beneficiary is still working for an employer with 50 employees and has group coverage based on current employment. The claim should go to the group health plan first, then to Medicare as secondary, because the working-aged MSP rule applies. If the patient were retired and covered only by Medicare, Medicare would be primary. The MSP questionnaire and employer verification support the order.
Traps
Assuming Medicare is always primary; treating an expired eligibility check as current; missing prior authorization or referral requirements; ignoring payer-specific timely filing; billing a Medicare noncovered service without a valid ABN; and submitting a claim without the primary payer's EOB when secondary billing requires it.