Coverage and Benefits
What does a benefit investigation (BI) determine?
Patient insurance coverage and benefits
What does ARM stand for?
Access & Reimbursement Manager
The office says they never received the enrollment form. Whats your first action?
Verify how it was sent and resent appropriately
True or False:
ARMs can recommend coding changes to increase reimbursement
False
What does "Beyond the Ask" mean?
Solving additional office needs beyond the original question
What are the two major types of medical insurance in the United States?
Commercial and Government
What is the ARM's primary role?
Educate and support access processes while remaining compliant
A claim denied for missing documentation. Your first step?
Identify denial reason and educate on required documentation
Who determines medical necessity?
The treating provider
Name one question you could ask after resolving an issue.
"Is there anything else impacting patient access?"
Under what Medicare part is most physician administered infused oncology drugs covered?
Medicare Part B
What is one thing an ARM should never provide?
Clinical advice or treatment recommendations
A practice says reimbursement is taking too long. Name one thing to investigate.
Claim status, payer processing, missing information, coding
What should you do if an office asks you to make a coverage decision?
An office asks about one patient. What opportunity might you explore?
Other pending patients, workflow, education needs, payer trends
True or False:
Prior authorization approval guarantees payment
False
Why is documenting interactions important?
Complaince, continuity, and accurate follow up
A patient changes insurance mid treatment. What should be reassessed?
Benefits investigation and authorization requirements.
Can PHI be discussed over unsecured email?
No
Why is proactive outreach valuable?
It prevents future barriers and strengthens partnership
Name three factors that influence patient out of pocket cost?
Deductible, coinsurance, copay, out of pocket maximum, secondary insurance, assistance eligibility
A provider asks you to complete a prior authorization form for them. What should you do?
Educate on requirements but the provider remains responsible for completion.
An office says, "Insurance always denies this drug" What is the best FRM response?
Explore the specific denial reason and discuss available access resources.
Name two compliance principles that every ARM should remember.
Stay within approved resources, avoid clinical advice, protect PHI, remain non promotional, educate rather than direct office workflow
An office mentions staff turnover. What's an appropriate ARM opportunity?
Offer compliant onboarding education, access process refreshers, and available resources.