Insurance Basics
What does EOB stand for?
Answer: Explanation of Benefits
What does authorization confirm?
Answer: Approval from insurance to perform a service.
What form is used for professional claims?
Answer: CMS‑1500
What is a denial?
Answer: When the payer refuses to pay a claim.
What does AR stand for?
Answer: Accounts Receivable
Which insurance type is considered the payer of last resort?
Answer: Medicaid
Name one method to check patient eligibility.
Answer: Insurance portals, Availity, phone verification, or clearinghouse tools.
What does ICD‑10 code represent?
Answer: Diagnosis
Name one common denial reason.
Answer: Eligibility, coding error, missing information, authorization not obtained.
What is the purpose of payment posting?
Answer: To apply insurance/patient payments to the account correctly.
What is the fixed amount a patient pays at the time of service?
Answer: Copay
True or False: An authorization guarantees payment.
Answer: False
What does CPT code represent?
Answer: Procedure or service performed
What document is typically needed for an appeal?
Answer: Appeal letter + supporting documents (notes, codes, EOB).
What is timely filing appeal?
Answer: Requesting reconsideration when the payer denies due to filing limits.
What is the term for the amount a patient must pay before insurance begins to pay?
Answer: Deductible
If an authorization is not obtained, what type of denial may occur?
Answer: Authorization/Precert denial
What does “clean claim” mean?
Answer: Claim without errors that can be processed immediately.
How soon should a denial be worked after receipt?
Answer: As soon as possible (typically within 48–72 hours).
Name one indicator that a claim needs follow‑up.
Answer: No response from payer, unpaid after expected timeframe, system alert.
What is Coordination of Benefits (COB)?
Answer: Determining which insurance plan pays first, second, etc.
What information is required to request an authorization? (Name 2)
Answer: Diagnosis, CPT codes, patient demographics, provider NPI, date of service.
What is the typical timeframe to submit a claim (filing limit)?
Answer: Depends on payer (often 90–180 days).
What is the difference between a denied claim and a rejected claim?
Answer:
What is the typical AR follow‑up cycle for insurance claims?
Answer: 21–30 days depending on payer.