Health Insurance Inquiry and Processing
This domain tests how well you can determine coverage before the visit, route the claim correctly, and resolve denials. Expect questions on plan types, Medicare parts, eligibility transactions, prior authorization, claim form fields, coordination of benefits, and appeals.
Plan types
- HMO: network only, PCP gatekeeper, referrals required.
- PPO: in- and out-of-network benefits, no referral needed.
- EPO: network only, no referrals.
- POS: HMO-style gatekeeping with out-of-network option.
- HDHP paired with an HSA.
- Medicare: Part A hospital, Part B medical, Part C Medicare Advantage, Part D drugs. Also Medicaid, TRICARE, and workers' compensation.
Verification workflow
- Run the 270/271 eligibility transaction or call the payer.
- Confirm effective date, network status, remaining deductible, copay, coinsurance, out-of-pocket maximum, and prior-authorization or referral requirements.
- Obtain authorization before the service, not after.
- CMS-1500: patient information, insured information, diagnosis codes (box 21), service lines with CPT and modifiers (box 24), billing provider NPI and TIN.
- Track timely filing and the payer's appeal levels.
Worked example
Two parents each cover their child. The birthday rule makes the plan of the parent whose birthday falls earlier in the calendar year primary (if the parents share a birthday, the plan covering the parent longer is primary). Bill the primary plan first, then submit to the secondary plan with the primary's EOB attached so the secondary can consider what the primary allowed and paid.
Traps that cost marks
- Billing the secondary before the primary EOB is available.
- Performing the service before authorization is on file.
- Confusing a copay (fixed dollar amount) with coinsurance (a percentage).
- Failing to check whether the provider is in network.
- Letting a claim age past the timely-filing limit while "waiting on the patient."