1
Q
- Q: What is the purpose of patient registration in the revenue cycle?
A
A: To collect and verify all patient demographic and insurance information needed to build an accurate claim before the encounter occurs.
2
Q
- Q: What three categories of information must be collected at patient registration?
A
A: Patient demographics, insurance information, and authorization and consent documents.
3
Q
- Q: What demographic information is required at patient registration?
A
A: Full legal name, date of birth, home address, Social Security Number, employer name and address, and phone number.
4
Q
- Q: Why must the patient’s full legal name be collected exactly as it appears on their insurance card?
A
A: A name mismatch between registration and insurance records causes claim rejection at submission.
5
Q
- Q: What insurance documentation must be collected at registration?
A
A: Insurance card front and back, member ID number, group number, insurance company name and contact information, and policyholder name and relationship to patient.
6
Q
- Q: Why must both the front and back of the insurance card be copied at registration?
A
A: The back of the card contains claims submission address and other critical billing information that is needed to submit the claim correctly.
7
Q
- Q: What is the member ID number?
A
A: The unique identifier assigned to the insured by the payer — required on every claim to link the service to the correct policy.
8
Q
- Q: What is the group number on an insurance card?
A
A: The identifier linking the patient to their employer-sponsored plan — required for accurate claim routing.
9
Q
- Q: What is an Assignment of Benefits?
A
A: A patient’s written authorization directing the insurance company to send payment directly to the provider rather than to the patient.
10
Q
- Q: What happens if an Assignment of Benefits is not obtained at registration?
A
A: The payer may send the payment check to the patient — if the patient cashes it without paying the provider, the practice absorbs the loss.
11
Q
- Q: What is a financial responsibility agreement in the registration context?
A
A: A signed patient acknowledgment accepting responsibility for any balance insurance does not cover.
12
Q
- Q: What government-issued identification should be verified at registration?
A
A: A valid government-issued photo ID such as a driver’s license, state ID, or passport.
13
Q
- Q: Why is secondary insurance information collected at registration?
A
A: To determine correct COB filing order and ensure both payers are billed in the correct sequence.
14
Q
- Q: What downstream problem results from missing registration information?
A
A: Claim rejections, incorrect payer billing, authorization failures, and denial of payment weeks after the service is rendered.
15
Q
- Q: What is eligibility verification?
A
A: The process of confirming before the encounter that the patient’s insurance is active, the provider is in-network, and the service will be covered.
16
Q
- Q: When must eligibility verification occur?
A
A: Before every encounter — not just for new patients — because insurance status changes frequently.
17
Q
- Q: Why is verifying eligibility at only the first visit insufficient?
A
A: Insurance changes due to job changes, open enrollment, or life events — coverage confirmed at one visit may be inactive at a later visit.
18
Q
- Q: What are the three methods used to verify patient eligibility?
A
A: Phone verification with the payer’s provider services line, payer online portal, and EDI 270/271 electronic transaction.
19
Q
- Q: What EDI transaction is sent to inquire about a patient’s eligibility?
A
A: The 270 transaction — the eligibility inquiry sent from provider to payer.
20
Q
- Q: What EDI transaction contains the payer’s response to an eligibility inquiry?
A
A: The 271 transaction — the eligibility response sent from payer to provider.
21
Q
- Q: What is the best method for high-volume practices to verify eligibility?
A
A: EDI 270/271 electronic transactions through a clearinghouse — automated and efficient for large patient volumes.
22
Q
- Q: What should a billing specialist do if coverage cannot be confirmed before a visit?
A
A: Document the verification attempt, collect estimated patient responsibility upfront, and bill as self-pay if needed.
23
Q
- Q: What is a copayment?
A
A: A fixed dollar amount due at time of service that does not apply toward the patient’s annual deductible.
24
Q
- Q: When is a copayment collected?
A
A: At the time of service — before or at the visit, not after insurance adjudicates.
25
25. Q: Does a copayment apply toward the deductible?
A: No — a copayment and a deductible are two completely separate patient financial obligations.
26
26. Q: What is a deductible?
A: The annual amount the patient must pay out of pocket before insurance begins paying for covered services.
27
27. Q: When does most patients' deductibles reset?
A: January 1 of each plan year for most insurance plans.
28
28. Q: What is coinsurance?
A: The percentage of costs shared between the patient and payer after the deductible has been fully met — always expressed as the patient's share.
29
29. Q: If a patient's coinsurance is 20%, what does the payer pay after the deductible is met?
A: The payer pays 80% of the allowed amount and the patient pays the remaining 20%.
30
30. Q: What is the out-of-pocket maximum?
A: The annual ceiling on total patient spending — once reached, the payer covers 100% of covered services for the remainder of the plan year.
31
31. Q: What happens after a patient meets their out-of-pocket maximum?
A: The payer covers 100% of covered services for the rest of the plan year — the patient owes nothing additional for covered services.
32
32. Q: What four components make up patient financial responsibility?
A: Copayment, deductible, coinsurance, and out-of-pocket maximum.
33
33. Q: What is stop-loss in a self-funded health plan?
A: The employer's equivalent of an out-of-pocket maximum that caps the employer's financial exposure per employee or in aggregate for the plan year.
34
34. Q: Does stop-loss protect the patient or the employer?
A: The employer — stop-loss protects the self-funded employer from catastrophic claims costs, not the patient directly.
35
35. Q: A patient has a $1,500 deductible with $600 met, 20% coinsurance, and a $600 allowed visit. What does the patient owe?
A: The patient owes $300 — the entire allowed amount applies to the remaining $900 deductible since it has not yet been met.
36
36. Q: A patient has fully met their $1,000 deductible and has 20% coinsurance. The allowed amount for a visit is $200. What does the patient owe?
A: The patient owes $40 — 20% of the $200 allowed amount since the deductible has been fully met.
37
37. Q: What is the difference between active and inactive insurance coverage at time of service?
A: Active coverage means the payer will process the claim; inactive coverage means the patient is financially responsible for the full allowed amount.
38
38. Q: What is Coordination of Benefits?
A: The process for determining which insurance plan pays first and how payment flows between payers when a patient has more than one insurance plan.
39
39. Q: What is the primary payer?
A: The insurance plan that pays first and up to its allowed amount before any other payer is billed.
40
40. Q: What is the secondary payer?
A: The insurance plan that applies its benefits to the remaining balance after the primary payer has adjudicated.
41
41. Q: What is a tertiary payer?
A: A third insurance plan that addresses any remaining balance after both the primary and secondary payers have paid.
42
42. Q: Can a patient collect more than 100% of actual charges through COB?
A: No — COB is designed to prevent a patient from profiting from insurance — total payments cannot exceed actual charges.
43
43. Q: What is the Birthday Rule?
A: When a dependent child is covered under both parents' plans, the plan of the parent whose birthday falls earliest in the calendar year is primary.
44
44. Q: Does the Birthday Rule use the parents' ages or their birthdays?
A: Calendar year birthday dates — month and day only — not the parents' ages.
45
45. Q: Parent A has a birthday on March 5 and Parent B has a birthday on November 12. Which plan is primary for their dependent child?
A: Parent A's plan — March comes before November in the calendar year.
46
46. Q: Parent A is 45 years old with a birthday on August 20 and Parent B is 38 years old with a birthday on February 14. Which plan is primary?
A: Parent B's plan — February comes before August in the calendar year regardless of age.
47
47. Q: What happens if both parents share the same birthday under the Birthday Rule?
A: The plan that has covered the dependent the longest is primary.
48
48. Q: Under COB rules for divorced parents, which plan is primary for a dependent child in the absence of a court order?
A: The custodial parent's plan is primary.
49
49. Q: Under COB rules for divorced parents, if the custodial parent has remarried, what is the order of coverage for a dependent child?
A: Custodial parent's plan first, stepparent's plan second, non-custodial parent's plan third.
50
50. Q: What governs COB filing order when a court order exists specifying insurance responsibility?
A: The court order takes precedence — the plan specified in the court order is primary.
51
51. Q: What are the Medicare Secondary Payer rules?
A: Rules establishing when Medicare is not the primary payer — Medicare becomes secondary to employer group health plans, workers' compensation, no-fault, and liability insurance.
52
52. Q: When is an employer group health plan primary over Medicare?
A: When the employer has 20 or more employees and the patient is actively working and enrolled in the group health plan.
53
53. Q: When is an employer group health plan primary over Medicare for a disabled patient under 65?
A: When the employer has 100 or more employees.
54
54. Q: When is workers' compensation the primary payer over Medicare?
A: When the patient's condition is work-related and covered under workers' compensation — always primary over Medicare for those specific services.
55
55. Q: When is no-fault insurance primary over Medicare?
A: When the patient's condition resulted from an automobile accident or other event covered by no-fault insurance.
56
56. Q: When is liability insurance primary over Medicare?
A: When a third party is legally liable for the patient's injury or illness — liability insurance pays before Medicare.
57
57. Q: What is an HMO?
A: A Health Maintenance Organization — a plan requiring a primary care physician and referrals to see specialists with strict in-network only coverage.
58
58. Q: What is the gatekeeper model in HMO plans?
A: The primary care physician controls all referrals to specialists — the patient cannot self-refer and must have a PCP-generated referral to see a specialist.
59
59. Q: Does an HMO cover out-of-network services?
A: Only in true emergencies — routine out-of-network services are not covered under HMO plans.
60
60. Q: What is the billing consequence of submitting an HMO claim without a required referral?
A: The claim is denied — a missing required referral results in automatic claim denial.
61
61. Q: What is a PPO?
A: A Preferred Provider Organization — a plan with no PCP requirement, no referral needed, and both in-network and out-of-network coverage available.
62
62. Q: What is the difference in cost-sharing between in-network and out-of-network services in a PPO?
A: In-network services have lower cost-sharing; out-of-network services have higher patient cost-sharing but are still covered.
63
63. Q: Why is the PPO the most commonly encountered plan type in outpatient physician billing?
A: It is the most flexible commercial plan — no referral requirement, broad network access, and out-of-network coverage make it widely used.
64
64. Q: What is an EPO?
A: An Exclusive Provider Organization — a plan with no referral requirement but strictly in-network only coverage with no out-of-network benefits except emergencies.
65
65. Q: How does an EPO combine features of HMO and PPO plans?
A: It has no referral requirement like a PPO but has no out-of-network benefits like an HMO.
66
66. Q: What is the key billing distinction between a PPO and an EPO?
A: A PPO covers out-of-network services at higher cost-sharing; an EPO provides no out-of-network coverage for non-emergency services.
67
67. Q: What is an indemnity or fee-for-service plan?
A: A plan allowing the patient to see any provider with the payer reimbursing a percentage of charges after the fact — no network restriction applies.
68
68. Q: Why are indemnity plans becoming increasingly rare?
A: They are the most expensive plan type for insurers — unrestricted provider access and retrospective reimbursement make them cost-prohibitive for most employers.
69
69. Q: What is a High-Deductible Health Plan?
A: A plan with a higher-than-standard deductible threshold set annually by the IRS — designed to be paired with a Health Savings Account.
70
70. Q: What is a Health Savings Account?
A: A tax-advantaged account paired with an HDHP allowing patients to save pretax dollars for qualified medical expenses.
71
71. Q: What federal law governs self-funded employer health plans?
A: ERISA — the Employee Retirement Income Security Act — which preempts state insurance regulations.
72
72. Q: What law governs fully insured employer health plans?
A: State insurance commission regulations — fully insured plans are subject to state insurance mandates.
73
73. Q: What is the billing implication of a self-funded versus fully insured plan?
A: Self-funded plans follow ERISA and are not subject to state mandates — billing rules may differ from state-regulated fully insured plans.
74
74. Q: What does Medicare Part A cover?
A: Inpatient hospital care, skilled nursing facility, hospice, and some home health services.
75
75. Q: What does Medicare Part B cover?
A: Outpatient services, physician services, preventive care, and durable medical equipment.
76
76. Q: What is Medicare Part C?
A: Medicare Advantage — a private plan option combining Part A and B benefits offered by CMS-approved private insurers — it replaces Original Medicare.
77
77. Q: What does Medicare Part D cover?
A: Outpatient prescription drug coverage — available as a standalone plan or bundled with Medicare Advantage.
78
78. Q: Who is eligible for Medicare?
A: Individuals age 65 or older, individuals under 65 with a qualifying disability, and individuals with End-Stage Renal Disease or ALS.
79
79. Q: Does Medicare Part A require a monthly premium for most beneficiaries?
A: No — most beneficiaries receive Part A premium-free because they or their spouse paid Medicare taxes for at least 40 quarters.
80
80. Q: Does Medicare Part B require a monthly premium?
A: Yes — Part B requires a monthly premium, is subject to an annual deductible, and has 20% coinsurance after the deductible is met.
81
81. Q: What is Medicare Advantage and how does it differ from Original Medicare?
A: Medicare Advantage replaces Original Medicare through a CMS-approved private plan — it may have network restrictions and different cost-sharing than Original Medicare.
82
82. Q: Can a Medicare Advantage plan include Part D drug coverage?
A: Yes — many Medicare Advantage plans bundle Part D prescription drug coverage into the plan.
83
83. Q: What is Medigap?
A: Private insurance that supplements Original Medicare by covering cost-sharing gaps such as deductibles and coinsurance — it does not replace Medicare.
84
84. Q: Does Medigap replace Original Medicare?
A: No — Medigap supplements Original Medicare by covering what Medicare leaves unpaid — the patient must remain enrolled in Original Medicare Parts A and B.
85
85. Q: What is the critical distinction between Medigap and Medicare Advantage?
A: Medicare Advantage replaces Original Medicare; Medigap supplements Original Medicare — a patient cannot hold both simultaneously.
86
86. Q: Can a Medicare Advantage enrollee purchase a Medigap policy?
A: No — Medigap can only be used with Original Medicare and cannot be combined with Medicare Advantage.
87
87. Q: What does Medigap Plan G cover?
A: All Medicare cost-sharing gaps except the Part B deductible — currently the most comprehensive Medigap plan available to new enrollees.
88
88. Q: What is dual eligibility?
A: A patient covered by both Medicare and Medicaid simultaneously — Medicare pays first and Medicaid pays second as the payer of last resort.
89
89. Q: What does a dual-eligible patient typically owe out of pocket?
A: Little to nothing — Medicaid covers the Medicare cost-sharing that the patient would otherwise owe.
90
90. Q: What is a crossover claim?
A: A claim that automatically transfers from Medicare to Medicaid after Medicare adjudicates for dual-eligible patients — the provider does not need to manually submit to Medicaid.
91
91. Q: What is Medicaid?
A: A joint federal and state funded program providing health coverage primarily to low-income individuals — eligibility and covered services vary significantly by state.
92
92. Q: What is Medicaid's role in COB?
A: Medicaid is always the payer of last resort — it pays after all other insurance coverage has been applied.
93
93. Q: How does Medicaid eligibility differ from Medicare eligibility?
A: Medicare eligibility is based on age or disability; Medicaid eligibility is based primarily on income — means-tested.
94
94. Q: Why do Medicaid billing rules vary?
A: Because Medicaid is a joint federal-state program — each state administers its own program within federal guidelines, creating state-specific coverage and billing rules.
95
95. Q: What is TRICARE?
A: Health coverage for active duty military personnel, veterans, and their families — administered by the Department of Defense.
96
96. Q: What are the three major TRICARE plan types?
A: TRICARE Prime, TRICARE Select, and TRICARE For Life.
97
97. Q: What is TRICARE Prime?
A: An HMO-like TRICARE plan requiring selection of a primary care manager and referrals for specialist visits.
98
98. Q: What is TRICARE Select?
A: A PPO-like TRICARE plan with no referral requirement and both in-network and out-of-network coverage options.
99
99. Q: What is TRICARE For Life?
A: A TRICARE plan for military beneficiaries age 65 and older that acts as secondary to Medicare — Medicare pays first, TRICARE For Life covers remaining cost-sharing.
100
100. Q: Who pays first when a patient has both Medicare and TRICARE For Life?
A: Medicare pays first — TRICARE For Life is always secondary to Medicare for beneficiaries age 65 and older.
101
101. Q: What is a referral in the insurance authorization context?
A: An order from a PCP directing a patient to a specialist — required primarily for HMO plans and must be obtained before the specialist visit occurs.
102
102. Q: For which plan type is a referral most commonly required?
A: HMO plans — the gatekeeper model requires PCP-generated referrals for all specialist services.
103
103. Q: What is precertification?
A: Payer approval obtained before a specific service is performed — binding once approved and required for many procedures, surgeries, imaging studies, and hospitalizations.
104
104. Q: What is preauthorization?
A: Another term for precertification — payer approval obtained before a service is rendered.
105
105. Q: What is predetermination?
A: A non-binding estimate from the payer of what it will pay for a proposed service — it does not guarantee coverage or constitute approval.
106
106. Q: What is the key difference between precertification and predetermination?
A: Precertification is binding payer approval required before a service; predetermination is a non-binding cost estimate that does not guarantee payment.
107
107. Q: What is the difference between a referral and a precertification?
A: A referral is a PCP order directing the patient to a specialist; precertification is payer approval for a specific service to be performed.
108
108. Q: What services typically require precertification?
A: Major procedures, elective surgeries, advanced imaging such as MRI and CT, and inpatient hospitalizations.
109
109. Q: In which box of the CMS-1500 is the authorization number entered?
A: Box 23.
110
110. Q: What is the claim denial consequence of performing a service without required precertification?
A: The claim is denied for missing or invalid authorization — retroactive authorization for elective services is rarely granted.
111
111. Q: What is retroactive authorization?
A: Payer approval granted after a service has already been performed — sometimes available for emergent situations but rarely approved for elective procedures.
112
112. Q: Why should retroactive authorization never be assumed for elective services?
A: Payers rarely grant it — assuming it will be approved is one of the most costly billing mistakes in authorization management.
113
113. Q: What is the EDI transaction used to submit authorization requests electronically?
A: The 278 transaction — the authorization request and response.
114
114. Q: What is an Advanced Beneficiary Notice?
A: A written notice given to a Medicare fee-for-service beneficiary before a service Medicare may not cover — informing the patient they may be financially responsible for the cost.
115
115. Q: To which patients does the ABN apply?
A: Medicare fee-for-service beneficiaries only — not Medicaid patients, commercial insurance patients, or Medicare Advantage patients.
116
116. Q: Does the ABN apply to Medicare Advantage patients?
A: No — the ABN is a Medicare fee-for-service document exclusively and provides no protection for Medicare Advantage patients.
117
117. Q: When is an ABN required?
A: When the provider believes Medicare will deny the service as not medically necessary or as a non-covered service under specific circumstances.
118
118. Q: When is an ABN voluntary rather than required?
A: When the service is always excluded from Medicare coverage — the ABN is optional but may be issued to inform the patient of their financial responsibility.
119
119. Q: What are the three patient options on an ABN?
A: Option 1 — patient wants the service and agrees to pay if Medicare denies; Option 2 — patient wants the service but does not want Medicare billed; Option 3 — patient refuses the service.
120
120. Q: What billing action follows ABN Option 1?
A: The provider bills Medicare with modifier GA on file — if Medicare denies, the provider bills the patient for the allowed amount.
121
121. Q: What billing action follows ABN Option 2?
A: The provider does not bill Medicare — the patient pays the full amount upfront without a claim being submitted.
122
122. Q: What billing action follows ABN Option 3?
A: The service is not provided — the patient signs confirming refusal and no claim is submitted.
123
123. Q: What happens if a provider fails to issue an ABN and Medicare denies the claim for medical necessity?
A: The provider typically cannot collect from the patient and must absorb the financial loss.
124
124. Q: What HCPCS modifier is used when an ABN is on file?
A: Modifier GA — indicates the provider has an ABN signed by the patient on file.
125
125. Q: What does HCPCS modifier GY indicate?
A: The item or service is statutorily excluded from Medicare coverage — always non-covered regardless of medical necessity.
126
126. Q: What does HCPCS modifier GZ indicate?
A: The item is expected to be denied as not medically necessary and no ABN is on file — the provider cannot collect from the patient.
127
127. Q: What is the difference between modifier GA and modifier GZ?
A: GA indicates an ABN is on file protecting the provider's right to collect from the patient; GZ indicates no ABN was obtained and the provider cannot bill the patient.
128
128. Q: What is a waiver of liability in the Medicare context?
A: A limitation on liability provision that may protect the patient or provider from paying for services denied for reasons they could not reasonably have known about.
129
129. Q: What is the difference between an ABN and a waiver of liability?
A: An ABN is a proactive notice issued before a service; a waiver of liability is a retrospective determination of whether the provider or patient should have known a denial was likely.
130
130. Q: What services never require an ABN?
A: Services that are always excluded from Medicare coverage under any circumstance — for these, modifier GY is used instead.
131
131. Q: What is the payer of last resort in all multi-payer situations?
A: Medicaid — it always pays after all other coverage has been applied.
132
132. Q: How does COB affect the amount the patient owes?
A: The patient never owes more than the primary payer's allowed amount — COB is designed to coordinate payment without shifting excess cost to the patient.
133
133. Q: Does COB mean the two payers split the bill equally?
A: No — each payer applies its own benefit structure; the split is not equal and depends on each plan's specific payment rules.
134
134. Q: What is a participating provider?
A: A provider who has signed a contract with the payer agreeing to accept the payer's allowed amount as payment in full.
135
135. Q: What is a non-participating provider?
A: A provider who has not signed a contract with the payer — may bill above the payer's allowed amount depending on the plan type.
136
136. Q: What is balance billing?
A: Billing the patient for the difference between the provider's billed charge and the payer's allowed amount — prohibited for participating providers under most contracts.
137
137. Q: What is an in-network provider?
A: A provider who has contracted with the payer and is part of the plan's approved network — services are covered at the lower cost-sharing tier.
138
138. Q: What is an out-of-network provider?
A: A provider who has not contracted with the payer — services may be covered at a higher cost-sharing tier or not covered at all depending on the plan type.
139
139. Q: What is a primary care physician in the HMO context?
A: The designated provider responsible for managing the patient's overall care and generating referrals to specialists — required for HMO enrollment.
140
140. Q: What is a primary care manager in TRICARE?
A: The TRICARE equivalent of an HMO primary care physician — required for TRICARE Prime enrollment and referrals.
141
141. Q: What is an explanation of benefits?
A: The document the payer sends to the patient explaining how a claim was processed — showing billed amount, allowed amount, payer payment, and patient responsibility.
142
142. Q: What is the difference between an EOB and a remittance advice?
A: Both contain the same adjudication data — the EOB is sent to the patient and the remittance advice is sent to the provider.
143
143. Q: What is a POS code in the insurance eligibility context?
A: A place of service code on the claim indicating where the service was rendered — affects benefit application for some plan types.
144
144. Q: What is prior authorization and when is it required?
A: Payer approval obtained before a service is rendered — required for procedures, surgeries, imaging, and admissions specified in the payer's coverage policy.
145
145. Q: What is the difference between prior authorization and a referral?
A: A referral is a physician order directing care; prior authorization is payer approval for the service to be covered — both may be required simultaneously.
146
146. Q: What is a benefit period in Medicare Part A?
A: A period beginning the day a patient is admitted to a hospital or SNF and ending after 60 consecutive days without inpatient or SNF care — affects deductible application.
147
147. Q: How many benefit periods can a Medicare Part A beneficiary have?
A: Unlimited — there is no cap on the number of benefit periods, but a new deductible applies to each new benefit period.
148
148. Q: What is the Medicare Part B annual deductible?
A: A fixed amount set annually by CMS that the patient pays before Part B begins covering outpatient services — subject to annual adjustment.
149
149. Q: What is the Medicare Part B coinsurance rate after the deductible is met?
A: 20% — the patient pays 20% of the Medicare-approved amount and Medicare pays 80%.
150
150. Q: What is a Medicare Summary Notice?
A: The document Medicare sends to beneficiaries summarizing claims processed on their behalf — the Medicare equivalent of a commercial EOB.
151
151. Q: What is an open enrollment period?
A: A designated annual window during which patients may enroll in, change, or drop insurance plans — outside this window, changes are generally restricted to qualifying life events.
152
152. Q: What is a qualifying life event in the insurance context?
A: An event such as marriage, birth, job loss, or divorce that allows a patient to change insurance coverage outside the standard open enrollment period.
153
153. Q: What is a special enrollment period?
A: A window outside of open enrollment during which a patient may enroll in or change coverage due to a qualifying life event.
154
154. Q: What is the Medicare Initial Enrollment Period?
A: A 7-month window around a beneficiary's 65th birthday during which they can enroll in Medicare Parts A and B without late enrollment penalties.
155
155. Q: What is a Medicare late enrollment penalty?
A: A permanent premium increase applied when a beneficiary fails to enroll in Medicare Part B or Part D during their initial enrollment period without creditable coverage.
156
156. Q: What is creditable coverage in the Medicare context?
A: Coverage from an employer group health plan or other source that is at least as good as Medicare — prevents the late enrollment penalty when the patient eventually enrolls.
157
157. Q: What is a Medicare Advantage plan's network restriction?
A: Most Medicare Advantage plans require the patient to use in-network providers — out-of-network services may not be covered except in emergencies.
158
158. Q: How does a Medicare Advantage plan differ from Original Medicare in billing?
A: Medicare Advantage follows the private plan's specific rules, network, and cost-sharing — billing goes to the Medicare Advantage plan, not to Original Medicare.
159
159. Q: What is the TRICARE authorization requirement for TRICARE Prime?
A: Referrals from the primary care manager are required for specialist visits — similar to an HMO gatekeeper model.
160
160. Q: What is TRICARE Select's network flexibility compared to TRICARE Prime?
A: TRICARE Select does not require referrals and covers both in-network and out-of-network services — similar to a PPO model.
161
161. Q: What is a formulary in the context of Medicare Part D?
A: The list of prescription drugs covered by a specific Part D plan — drugs not on the formulary may not be covered or may require prior authorization.
162
162. Q: What is the coverage gap in Medicare Part D?
A: A phase of Part D coverage where the patient pays a higher percentage of drug costs after reaching an initial coverage limit — commonly known as the donut hole.
163
163. Q: What is catastrophic coverage in Medicare Part D?
A: The phase of Part D coverage reached after the patient has spent a specified out-of-pocket amount — the patient pays minimal cost-sharing for the remainder of the plan year.
164
164. Q: What is a Medicare plan finder?
A: A CMS tool that helps beneficiaries compare Medicare Advantage and Part D plans based on their geographic area and medication needs.
165
165. Q: What is a network adequacy requirement?
A: A regulatory standard requiring insurance plans to have a sufficient number of in-network providers to ensure members can access timely care.
166
166. Q: What is an insurance card verification step that is frequently missed at registration?
A: Copying the back of the insurance card — the front contains member ID and group number but the back contains claims submission address and customer service information.
167
167. Q: What is COB in the context of a patient with Medicare and a commercial plan?
A: The commercial plan's primary versus secondary status depends on MSP rules — if the commercial plan is primary, it pays first before Medicare applies.
168
168. Q: What is a managed care organization?
A: An entity that integrates financing and delivery of healthcare services — typically using networks, utilization management, and authorization requirements to manage costs.
169
169. Q: What is utilization management?
A: The process payers use to evaluate the medical necessity and appropriateness of services — includes prior authorization, concurrent review, and retrospective review.
170
170. Q: What is retrospective review in utilization management?
A: A post-service review by the payer to determine whether a service met medical necessity criteria — may result in denial of payment after the service has been rendered.
171
171. Q: What is a concurrent review?
A: An ongoing payer review of an inpatient stay to confirm continued medical necessity for the admission — conducted during the hospitalization.
172
172. Q: What is the difference between a precertification and a concurrent review?
A: Precertification occurs before admission; concurrent review occurs during the inpatient stay to validate continued medical necessity.
173
173. Q: What is a case manager in the insurance context?
A: A payer or provider representative who coordinates care for complex cases — often involved in authorization and discharge planning for high-cost patients.
174
174. Q: What is a step therapy requirement?
A: A payer policy requiring a patient to try and fail less expensive treatments before the payer will authorize a more expensive treatment.
175
175. Q: What is a formulary exception?
A: A request to a Part D or commercial plan to cover a drug not on the formulary — requires documentation that the formulary drug is ineffective or contraindicated.
176
176. Q: What is a Medicare Advantage Special Needs Plan?
A: A specialized Medicare Advantage plan designed for specific populations such as dual-eligible patients, institutionalized patients, or those with specific chronic conditions.
177
177. Q: What is a dual-eligible Special Needs Plan?
A: A Medicare Advantage plan specifically designed for patients who qualify for both Medicare and Medicaid — coordinates benefits between both programs.
178
178. Q: What is the income threshold for Medicaid eligibility?
A: It varies by state — states set their own eligibility thresholds within federal guidelines, and the ACA allowed states to expand Medicaid to adults up to 138% of the federal poverty level.
179
179. Q: What is Medicaid expansion under the ACA?
A: The option for states to expand Medicaid eligibility to adults under 65 with incomes up to 138% of the federal poverty level — not all states have expanded.
180
180. Q: What is CHIP?
A: The Children's Health Insurance Program — a joint federal-state program providing health coverage to children in families with incomes too high for Medicaid but too low for private insurance.
181
181. Q: How does CHIP relate to Medicaid in billing?
A: CHIP functions similarly to Medicaid in billing — it is a government program with state-specific rules and low cost-sharing for enrolled children.
182
182. Q: What is a health exchange or marketplace plan?
A: An insurance plan purchased through the ACA marketplace — eligible individuals may receive premium tax credits and cost-sharing reductions based on income.
183
183. Q: What is a premium tax credit?
A: A federal subsidy provided through the ACA marketplace to help eligible individuals pay their insurance premiums — based on income and household size.
184
184. Q: What is cost-sharing reduction in ACA marketplace plans?
A: Additional subsidies that reduce deductibles, copayments, and coinsurance for eligible lower-income marketplace plan enrollees.
185
185. Q: What is a silver plan in the ACA marketplace context?
A: The benchmark plan tier in the ACA marketplace — cost-sharing reductions are available only through silver plans for eligible enrollees.
186
186. Q: What is COBRA?
A: The Consolidated Omnibus Budget Reconciliation Act — allows individuals who lose employer-sponsored coverage to continue that coverage temporarily by paying the full premium themselves.
187
187. Q: What is the maximum duration of COBRA coverage?
A: Generally 18 months for the employee — extended to 36 months in certain circumstances such as disability or a second qualifying event.
188
188. Q: Is COBRA coverage primary or secondary to Medicare?
A: Generally secondary — Medicare is typically primary when a beneficiary has both Medicare and COBRA coverage.
189
189. Q: What is a coordination period in the MSP context?
A: The period during which a non-Medicare payer is primary over Medicare — such as the 30-month Medicare Secondary Payer coordination period for ESRD patients.
190
190. Q: What is the ESRD coordination period under MSP rules?
A: During the first 30 months after a patient becomes eligible for Medicare due to End-Stage Renal Disease, the employer group health plan remains primary over Medicare.
191
191. Q: What is a plan year?
A: The 12-month period during which insurance benefits apply — deductibles, out-of-pocket maximums, and other accumulators reset at the start of each new plan year.
192
192. Q: What is the difference between a calendar year plan and a non-calendar year plan?
A: A calendar year plan runs from January 1 to December 31; a non-calendar year plan starts on a different date such as July 1 — affecting when deductibles and maximums reset.
193
193. Q: What is an accumulator in the insurance context?
A: A running total of amounts applied toward a patient's deductible or out-of-pocket maximum during the plan year.
194
194. Q: What is a network tier in pharmacy benefits?
A: A classification of pharmacies or drugs by cost-sharing level — preferred pharmacies or formulary drugs have lower cost-sharing than non-preferred options.
195
195. Q: What is a coordination of benefits agreement?
A: A document or provision within insurance policies establishing how each plan's benefits will be applied when a patient has multiple coverage sources.
196
196. Q: What is a non-duplication COB provision?
A: A COB rule where the secondary payer pays nothing if the primary payer's payment equals or exceeds what the secondary would have paid on its own.
197
197. Q: What is an integrated deductible?
A: A deductible that applies to both medical and pharmacy benefits together — amounts paid toward either category count toward the same annual deductible.
198
198. Q: What is an embedded deductible in a family plan?
A: An individual deductible within a family plan that allows a single family member's claims to be covered once their individual deductible is met — even if the family deductible has not been reached.
199
199. Q: What is an aggregate deductible in a family plan?
A: A family deductible structure where no individual coverage begins until the combined family spending meets the total family deductible.
200
200. Q: What is a carve-out benefit?
A: A specific benefit such as mental health, substance abuse, or dental coverage that is separated from the main medical plan and administered by a different entity.
201
201. Q: What is a behavioral health carve-out?
A: A separate insurance arrangement for mental health and substance abuse benefits — often administered by a different company with its own network and authorization requirements.
202
202. Q: What is a capitation payment model?
A: A payment arrangement where a provider receives a fixed per-member per-month payment to provide care for an enrolled population — regardless of the volume of services rendered.
203
203. Q: How does capitation affect billing in an HMO?
A: Under full capitation, the provider does not bill per service — they receive a fixed monthly payment and absorb the cost of all covered services for enrolled patients.
204
204. Q: What is a fee-for-service payment model?
A: A model where providers are paid for each individual service rendered — the basis for most commercial and Medicare billing.
205
205. Q: What is a value-based care arrangement?
A: A payment model tying provider reimbursement to quality metrics and patient outcomes rather than volume of services — designed to incentivize efficient, high-quality care.
206
206. Q: What is an Accountable Care Organization?
A: A group of providers who voluntarily coordinate care for Medicare patients and share in savings achieved through efficient, high-quality care.
207
207. Q: What is a Medigap open enrollment period?
A: A 6-month window beginning when a patient turns 65 and enrolls in Part B — during this period insurers must sell any Medigap plan at standard rates without medical underwriting.
208
208. Q: What happens if a patient tries to purchase Medigap outside the open enrollment period?
A: Insurers may deny coverage or charge higher premiums based on medical history — the guaranteed issue right no longer applies.
209
209. Q: What Medigap plans are available to new enrollees after January 1, 2020?
A: Plans A, B, D, G, K, L, M, and N — Plans C and F are no longer available to new enrollees because they cover the Part B deductible.
210
210. Q: Why were Medigap Plans C and F discontinued for new enrollees?
A: Federal law requires Medicare beneficiaries to have some cost-sharing exposure — Plans C and F covered the Part B deductible, eliminating all patient cost-sharing.
211
211. Q: What is the Medicare Annual Wellness Visit?
A: A preventive benefit under Medicare Part B that includes a health risk assessment and personalized prevention plan — covered at 100% with no cost-sharing after the first year.
212
212. Q: What is the Welcome to Medicare Preventive Visit?
A: A one-time Part B benefit available within the first 12 months of Medicare enrollment — includes a review of medical and social history and preventive screenings.
213
213. Q: What is Medicare's coverage of telehealth services as of 2026?
A: Telehealth coverage has been expanded — patients can receive telehealth services from their home using POS 10 with modifier 95 for synchronous audio-video visits.
214
214. Q: What is the difference between a Medicare-assigned and non-assigned claim?
A: An assigned claim means the provider accepts Medicare's allowed amount; a non-assigned claim means the provider may bill above the allowed amount subject to limiting charge rules.
215
215. Q: What is the Medicare limiting charge?
A: The maximum amount a non-participating provider can bill a Medicare patient — currently 115% of the Medicare fee schedule for non-participating providers.
216
216. Q: What is a participating provider agreement with Medicare?
A: An agreement where the provider accepts assignment on all Medicare claims — agreeing to accept Medicare's allowed amount as payment in full.
217
217. Q: What is a Medicare opt-out provider?
A: A provider who has officially opted out of Medicare and entered private contracts with patients — they cannot bill Medicare at all for non-emergency services.
218
218. Q: What is a private contract in the Medicare opt-out context?
A: A written agreement between an opt-out provider and a Medicare patient — the patient agrees to pay the provider directly with no Medicare reimbursement.
219
219. Q: What is Medicare's coverage of skilled nursing facility care under Part A?
A: Medicare covers SNF care following a qualifying 3-day inpatient hospital stay — covers days 1 through 20 at 100%, days 21 through 100 with patient coinsurance, nothing after day 100.
220
220. Q: What is Medicare's hospice benefit?
A: A Part A benefit for terminally ill patients with a life expectancy of 6 months or less who elect comfort care — covers hospice services with minimal patient cost-sharing.
221
221. Q: What is the hospice election in Medicare?
A: A formal patient choice to receive hospice care instead of curative treatment for the terminal condition — the patient waives Medicare coverage for curative treatment of that condition.
222
222. Q: What is Medicare's home health benefit?
A: Covered under both Parts A and B — provides medically necessary skilled nursing, therapy, and aide services to homebound patients with no cost-sharing for covered services.
223
223. Q: What qualifies a patient as homebound for Medicare home health coverage?
A: The patient has a condition that restricts their ability to leave home and leaving home requires considerable effort — they may leave for medical appointments or infrequent outings.
224
224. Q: What is the Medicare Advantage star rating system?
A: A CMS quality rating system for Medicare Advantage and Part D plans — plans rated higher receive bonus payments and may be marketed more broadly.
225
225. Q: What is a network exception in managed care?
A: A process allowing a patient to receive out-of-network care at in-network cost-sharing when a necessary provider or service is not available within the network.
226
226. Q: What is a continuity of care provision?
A: A managed care rule allowing a patient to continue seeing a provider who leaves the network for a transition period — often applies during active treatment or pregnancy.
227
227. Q: What is the No Surprises Act?
A: A federal law effective January 1, 2022 protecting patients from unexpected out-of-network bills for emergency services and certain non-emergency services at in-network facilities.
228
228. Q: How does the No Surprises Act affect billing for out-of-network emergency services?
A: Patients cannot be billed more than in-network cost-sharing amounts for emergency services — even if the provider is out-of-network.
229
229. Q: What is an independent dispute resolution process under the No Surprises Act?
A: A federal arbitration process allowing providers and payers to resolve payment disputes for out-of-network services covered by the No Surprises Act.
230
230. Q: What is good faith cost estimate?
A: A written estimate providers must give uninsured or self-pay patients before scheduled services — required under the No Surprises Act.
231
231. Q: What is a self-pay patient?
A: A patient without insurance or a patient who chooses to pay out of pocket without billing their insurance — financial responsibility policies for self-pay patients must be clearly communicated.
232
232. Q: What is a sliding fee scale?
A: A discounted fee structure for uninsured or low-income patients based on income and family size — commonly used by federally qualified health centers.
233
233. Q: What is a federally qualified health center?
A: A community-based health center receiving federal funding to provide care to underserved populations — eligible for enhanced Medicare and Medicaid reimbursement rates.
234
234. Q: What is a rural health clinic?
A: A Medicare and Medicaid certified clinic in a rural underserved area — eligible for cost-based reimbursement rates higher than standard Medicare rates.
235
235. Q: What is third-party liability in medical billing?
A: Situations where a third party such as an auto insurer, workers' compensation carrier, or liability insurer is responsible for paying the patient's medical costs.
236
236. Q: What is a lien in the medical billing context?
A: A legal claim against a patient's potential legal settlement — the provider agrees to treat the patient and be paid from the settlement proceeds.
237
237. Q: What is workers' compensation billing?
A: Billing for services related to a work-related injury or illness — billed to the workers' compensation carrier rather than health insurance.
238
238. Q: What is the billing implication when a service is related to a workers' compensation claim?
A: Workers' compensation is the primary payer — health insurance cannot be billed for services covered under workers' compensation.
239
239. Q: What is a motor vehicle accident claim in the medical billing context?
A: A claim where the patient's injuries resulted from an auto accident — billed to the no-fault or liability insurance carrier before health insurance.
240
240. Q: What is a coordination of benefits questionnaire?
A: A form sent to patients by payers to identify other insurance coverage — used to determine COB filing order and ensure correct primary billing.
241
241. Q: What is an insurance verification form?
A: A document used to record all insurance information collected at registration — serves as the source document for claim building and eligibility verification.
242
242. Q: What is a real-time eligibility check?
A: An instantaneous electronic verification of a patient's insurance eligibility and benefits performed through the payer portal or clearinghouse at or before the time of service.
243
243. Q: What is a payer portal?
A: A secure online platform provided by the insurance company allowing providers to verify eligibility, check claim status, submit authorizations, and retrieve remittance information.
244
244. Q: What is a network participation agreement?
A: A contract between a provider and an insurance plan establishing the terms of participation including accepted reimbursement rates, billing requirements, and network obligations.
245
245. Q: What is credentialing in the insurance context?
A: The process by which a payer verifies a provider's qualifications, licensure, and credentials before approving them to participate in the plan's network.
246
246. Q: What is re-credentialing?
A: The periodic process of re-verifying a provider's credentials and qualifications — typically required every two to three years by most payers.
247
247. Q: What is a provider enrollment application?
A: The application a provider submits to a payer to become a participating provider in that plan's network — triggers the credentialing process.
248
248. Q: What is a billing NPI in the insurance eligibility context?
A: The National Provider Identifier used on claims to identify the billing entity — may be the provider's Type 1 individual NPI or the practice's Type 2 organizational NPI.
249
249. Q: What is the relationship between eligibility verification and claim denial prevention?
A: Confirming active coverage, correct payer, in-network status, and benefit details before the visit prevents the most common and most avoidable claim denials in the revenue cycle.
250
250. Q: What is the single most important registration step that prevents downstream billing failures?
A: Verifying insurance eligibility before every encounter — confirming active coverage, correct plan information, and applicable authorization requirements before the patient is seen.
NHA CBCS EXAM
flashcards
Decks in class (6)
# Cards
