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 federal law requires most insurers to respond to prior authorization requests for urgent services within a specific timeframe?
Answer: No federal law currently exists for all plans
There is no single federal law covering all health plans for PA turnaround times; ERISA governs self-funded plans, and state laws vary for fully insured commercial plans.
What is the purpose of an 'authorization number'?
Answer: A unique identifier assigned by the payer confirming that a service has been authorized for coverage
An authorization number is a unique tracking number issued by the payer confirming approval of a requested service.
A patient with a PPO plan sees a specialist without a referral. What is likely to happen?
Answer: The service may be covered but potentially at a higher cost-sharing rate depending on plan rules
PPO plans generally allow self-referrals to specialists but may require prior authorization for certain services; cost-sharing may vary.
What is 'step therapy' and why is it relevant to prior authorization?
Answer: A treatment protocol requiring patients to try less costly or less intensive treatments before a more expensive one is approved
Step therapy (fail-first) requires patients to try and fail on first-line or less expensive treatments before a payer will authorize a more expensive option.
Which of the following is true about authorizations for durable medical equipment (DME)?
Answer: Medicare requires prior authorization for certain high-cost DME items
Medicare has a Prior Authorization Program for certain high-cost or frequently abused DME items to prevent unnecessary utilization.
When a referral is made from a PCP to a specialist, what information must be communicated?
Answer: The reason for referral, relevant clinical information, and any authorization numbers if required by the plan
An effective referral includes the clinical reason for referral, pertinent medical history, and any payer-required authorization information.
Which of the following is a key difference between a 'soft denial' and a 'hard denial' in prior authorization?
Answer: A soft denial can be resolved by submitting additional information; a hard denial is a final determination
A soft denial is a request for more information and can often be resolved by supplying the missing documentation; a hard denial is a final decision that requires a formal appeal.
What federal rule finalized in 2024 aims to reduce prior authorization burdens for Medicare Advantage, Medicaid, and CHIP plans?
Answer: CMS Interoperability and Prior Authorization Final Rule
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requires certain payers to implement APIs and faster PA response times.