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CCMA - Administrative Assisting - Section 5.3

Process insurance authorisations, pre-certifications, and verify patient eligibility and benefits.

Verify patient insurance eligibility and benefits at each visit and obtain prior authorisation or pre-certification before scheduled procedures. Distinguish the consequences of failing to obtain authorisation - claim denial and patient liability - and identify the appeal process when a claim is denied.

Insurance verificationPre-certificationEligibilityPrior authorisation

Practice question for this objective

Free sampleAdministrative Assistingmedium

A medical assistant is scheduling a screening colonoscopy for a 58 year old patient with commercial insurance. The provider's order is signed and the procedure is set for next week at an in-network ambulatory surgery centre. What is the BEST first administrative action to protect the patient from an unexpected denial?

  • ACollect the estimated patient responsibility at check-in and bill the payer afterwards, allowing the claims adjudication process to determine whether authorisation was needed.
  • BForward the order to the surgery centre and rely on their pre-admission team to obtain any required authorisation before the date of service.
  • CVerify the patient's active eligibility and confirm whether the payer requires prior authorisation for the CPT code, then submit the authorisation request with the clinical documentation. Correct
  • DAsk the patient to call the member services number on the back of their insurance card to confirm coverage and arrange any authorisation themselves.
Recognise that prior authorisation must be obtained by the ordering practice after verifying eligibility and before a scheduled non-emergent procedure. Prior authorisation is a payer's pre-service utilisation review that requires submission of clinical documentation against the payer's medical policy. Without an approved authorisation on file before the date of service, the claim is typically denied as no-auth, and per most contracts the practice, not the patient, absorbs the write-off, so verifying eligibility and securing authorisation up front is the protective workflow.

Why A is wrong: Tempting because point-of-service collection is part of revenue cycle work, but billing after the fact when prior authorisation was required produces an administrative denial that the patient may then owe in full; authorisation must precede the service.

Why B is wrong: Tempting because facilities often run their own pre-admission checks, but the ordering practice retains responsibility for the professional component authorisation; passing it off risks duplicate work and missed deadlines that leave the patient exposed.

Why C is correct: Correct because eligibility confirms the policy is active on the date of service and the payer's published medical policy dictates whether the CPT requires prior authorisation; submitting with clinical notes before the appointment is the standard workflow that prevents back-end denials.

Why D is wrong: Tempting because the member can confirm benefits, but obtaining prior authorisation is a provider responsibility based on submitted clinical documentation; the patient cannot supply the chart notes the payer needs to approve the request.

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