Insurance Eligibility and other payer requirements Flashcards
A minor patient, whose parents are married, is covered under both parents’ group insurance plans and also has Medicaid benefits. Parent A has a birthdate of June 6, 1988 and Parent B has a birthdate of October 23, 1987. Which insurance plan should be billed first?
a. Parent A’s insurance
b. Parent B’s insurance
c. Medicaid
d. Either parent A’s or parent B’s insurance
Parent A’s insurance
A billing and coding specialist is reviewing a patient’s record. the specialist should recognize that which of the following should be signed by the patient if there is a concern that Medicare might not pay for the services?
a. Informed consent form
b. Patient referral authorization form
c. Advanced Beneficiary Notice (ABN)
d. Notice of Privacy Practices (NPP)
Advanced Beneficiary Notice (ABN)
A billing and coding specialist is preparing a claim for a 69-year-old patient who was involved in a motor-vehicle crash. The specialists should submit the primary claim to which of the following third-party payers?
a. Medicaid
b. Private insurance
c. Medicare
d. Auto insurance
Auto insurance
A billing and coding specialist is reviewing insurance eligibility for a 49-year-old patient who has end-stage renal disease and multiple third-party payers. the specialist should recognize that which of the following payers is the primary?
a. Workers’ compensation
b. Medicare
c. Medicaid
d. TRICARE
Medicare
A billing and coding specialist is calculating a patient’s financial responsibility for a procedure. The charge for the procedure is $1,400 and the provider is in the patient’s insurance provider’s network. The allowable amount for the procedure is $500 with no deductible required. If the insurance plan pays 80/20, what is the patient’s total coinsurance amount?
a. $100
b. $280
c. $400
d. $500
$100
A billing and coding specialist is reviewing a patient’s insurance coverage and notices that the patient is covered by two group insurance plans: one through their own employer and one through their partner’s employer. The specialist should recognize that which of the following is true regarding the client’s primary insurance coverage?
a. Primary coverage is determined by the birthday rule.
b. Primary coverage is determined by the plan that has been in place the longest.
c. Primary coverage is provided through the patient’s plan.
d. Primary coverage is provided through the plan with the lowest deductible.
Primary coverage is provided through the patient’s plan.
A billing and coding specialist is preparing the registration for a patient who is covered under their spouse’s insurance. Which of the following items is required to complete the registration?
a. Patient demographics
b. Credit card
c. Spouse’s social security card
d. Work history
Patient demographics
A patient fell and was injured while picking up a catering order during their break for an all-employee staff meeting. Which of the following third-party payers is responsible for this encounter?
a. Auto insurance
b. Workers’ compensation
c. Homeowners insurance
d. Group health plan
Workers’ compensation
A billing and coding specialist is submitting a claim for a patient who experienced an injury from a fall during their lunch break away from the building. The specialist should recognize that which of the following is the correct primary payer for the claim?
a. Workers’ compensation
b. Out-of-pocket patient payment
c. Disability insurance
d. The patient’s group health insurance
The patient’s group health insurance
A billing and coding specialist is preparing a claim for a 16-year-old patient. Which of the following should be contacted to verify the child’s demographics?
a. The child’s school
b. Policyholder
c. Third-party payer
d. Patient
Policyholder
A patient who has Medicare coverage requests a pain medication refill following hip replacement surgery. For which the following parts of Medicare should the patient’s eligibility be verified for the prescription?
a. Part A
b. Part B
c. Part C
d. Part D
Part D
A patient is scheduled for a procedure with an allowed amount of $2,500, and the annual deductible of $700 has been met. The coinsurance agreement is 70/30. Which of the following is the patient’s responsibility?
a. $2,500
b. $1,450
c. $1,750
d. $750
$750
Which of the following parts of Medicare determines eligibility for dental services?
a. Part A
b. Part B
c. Part C
d. Part D
Part C
A patient completes their provider’s office registration forms and provides a military ID with a TRICARE card. The billing and coding specialist should use which of the following to verify the patient’s third-party payer eligibility?
a. The Electronic Data Interchange (EDI)
b. The Prospective Payment System (PPS)
c. The Defense Enrollment Reporting System (DEERS)
d. Integrated Delivery System (IDS)
The Defense Enrollment Reporting System (DEERS)
A billing and coding specialist is speaking with a patient on the phone regarding the fixed amount due for an upcoming visit. Which of the following terms refers to the fixed payment due per visit?
a. Copayment
b. Premium
c. Deductible
d. Coinsurance
Copayment
