Prior Authorization and Referrals Flashcards
8 cards from real CBCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 8 Prior Authorization and Referrals flashcards as text
Which payer type typically requires the most stringent prior authorization requirements?
Answer: Commercial HMO plans
Commercial HMO plans tend to have the most stringent prior authorization requirements because the gatekeeper model is central to their design.
What is the purpose of 'concurrent review' in utilization management?
Answer: To monitor ongoing inpatient care to verify continued medical necessity for continued stay
Concurrent review evaluates whether a patient's continued inpatient stay is medically necessary, typically conducted daily or every few days.
What is the consequence of billing for a service that required prior authorization but was not obtained?
Answer: The claim will likely be denied, and the provider may not be able to bill the patient
Claims without required prior authorization are typically denied, and in many contracts, the provider cannot balance-bill the patient for the denied amount.
What does the term 'medical necessity' mean in the context of insurance coverage?
Answer: Services that are reasonable and necessary for diagnosis or treatment of an illness or injury based on established clinical guidelines
Medical necessity means the service is reasonable, necessary, and appropriate for the patient's diagnosis or condition based on evidence-based criteria.
Which of the following is a common reason for prior authorization denial?
Answer: Insufficient clinical documentation to support medical necessity
Insufficient or incomplete clinical documentation is one of the most common reasons prior authorization requests are denied.
What is a 'letter of medical necessity' (LMN)?
Answer: A physician's detailed statement explaining why a specific treatment is medically necessary for a patient
A letter of medical necessity is written by the treating physician to explain and justify why a specific service is medically necessary for a particular patient.
In which scenario would a 'retrospective review' occur?
Answer: After emergency services are provided and stabilization has occurred
Retrospective review occurs after services have been rendered, most commonly after emergency care when prior authorization was not possible.
When should a billing specialist begin tracking a prior authorization request?
Answer: Immediately upon submission of the authorization request
Authorization tracking should begin immediately upon submission so turnaround times, status updates, and expiration dates can be monitored proactively.