Insurance Eligibility and Other Payer Requirements Flashcards
What is the Birthday Rule?
When the patient is a minor and has dual coverage from both parents, the parent whose birthday is first in the calendar year(don’t factor in the birth year) is the primary insurance. If the parents are divorced, the parent with custody or has the insurance longer will be primary.
What do you need for a patient who’s a minor?
You will need the Guarantor or Policy holder information.
What is a Guarantor?
The Guarantor holds financial responsibility for the patient’s health care bill.
What is a Policy Holder?
This is the owner of the health insurance.
What is an ABN?
It is an Advanced Beneficiary Notice. This is a form the patient must sign acknowledging Medicare might not cover the services they need. Must have reason the service is not covered.
What is COB?
Coordination of Benefits. This means the patient has dual coverage and reported their insurances in the wrong order. Primary insurance is actually the secondary insurance and vice versa.
What is an EMR?
It is an Electronic Medical Record used for one organization.
What is an EHR?
This is an Electronic Health Record used for multiple organizations.
What is a Premium?
What you pay monthly to keep your health insurance active.
What is a Deductible?
This is the amount the patient is responsible for before the insurance plan pays a percentage of the Allowable amount. Deductibles renew every year.
What is a Copay?
This is a fixed/set amount paid for each service. The insurance will pay the remaining allowable amount.
What is a Coinsurance?
This is the percentage of costs of covered services after the deductible has been met.
What is Care Credit?
This is a Credit Card that covers medical expenses. The provider will be paid in full and the patient will have a monthly statement like a normal credit card.
What is an HSA?
This is a Health Savings Account. The employer deducts a set amount from each paycheck(untaxed) and places funds on a medical card at the beginning of the year. They can use it for any OOP expense like deductible, coins, copays….
Why do you need Patient Registration?
This is when the patient fills out forms and the provider will receive all needed information in order to send a clean claim. This is where you get all patient demographics.
What is EDI?
Electronic Data Interchange
What is ED?
Emergency Department
What is NAIC?
National Association of Insurance Commissioner
What is Timely Filing?
It is when the organization is required to submit a claim to the insurance plan for services within an outlined time limit. If Timely Filing has passed, the provider is held liable.
What is the first step to insurance verification?
It is to collect the patient’s insurance information and verify their identity with a photo ID.
Why is verifying patient eligibility so important?
This identifies the primary payer and offers specific details about the patient’s coverage limits.
How can you verify insurance eligibility?
Through the plan’s eligibility call line, an online portal, electronic data interchange(EDI), or in your EHR via an eligibility application.
What information does the EDI lack when verifying eligibility?
It cannot provide remaining deductible amounts, coinsurance, or if authorization is required. You will have to contact the health care plan.
When calling a health insurance plan, how will they identify the patient?
Using the Member ID number and the group number on their insurance card.
What does it mean when a provider is in-network(INN)?
This is a provider who has signed an agreement with the insurance plan. They have established allowed amounts for each CPT code that the provider agrees to accept as payment in full.
What does it mean when a provider is out-of-network(OON)?
This is a provider who does not have a signed agreement with an insurance plan. If the patient does not have OON benefits, they will have to be Self pay.
Prior to scheduling, what should the specialist do?
Review patient benefits and verify that any utilization management requirements have been met. Like precertification or preauthorization.
What are Covered Benefits?
They are services outlined in the policy that are payable by the health plan.
What are Preventative Services?
These are offered to the policyholder with the intent to prevent or avoid health problems or injuries. Usually covered 100%, the deductible does not apply.
What are Non-Covered Benefits?
These are services not deemed medically necessary like cosmetic surgery.
What is an Out-Of-Pocket (OOP) Maximum?
This is the dollar amount required before full coverage begins.
What happens if a required referral, preauthorization, or reauthorization is not obtained?
The claim will be denied and you cannot bill the patient.
What are some Out-Of-Pocket Expenses the patient might have?
Copays, Coinsurances, Deductibles, and Non-Covered Services.
When should you collect patient payments?
At the time of services to increase cash collection and support the revenue cycle.
What is important when it comes to patient payments?
It is important to communicate the financial responsibility to the patient.
What are patients who do not have insurance referred to as?
Self-pay or Private pay
What is a Hardship Waiver?
It will reduce the amount the patient owes or eliminate it. The patient must show proof of hardship and Federal Poverty Level(FPL)
What factors into a patient’s Hardship or FPL?
Cost of living, Income, Family Size, and the Extent of the Patient’s Medical Bills.
What is a Tertiary Insurance?
This means the patient is covered by three insurance plans and this plan is billed last.
What is a Primary Insurance?
This insurance will pay first and the EOB will be sent along with the Secondary Claim.
What is Secondary Insurance?
Once the primary insurance pays, the secondary insurance will pay the remaining balance.
