Prior Authorization and Referrals Flashcards

What is the primary purpose of prior authorization in healthcare?

Answer: To verify that a proposed service meets the payer's criteria for medical necessity before it is performed

Prior authorization confirms that a payer agrees the service is medically necessary before it is performed, reducing denial risk.

Which document is typically required to initiate a prior authorization request?

Answer: Clinical notes supporting medical necessity

Clinical documentation supporting medical necessity (such as office notes, test results, and the treating physician's orders) is the primary requirement for a prior authorization request.

A payer denies a prior authorization request as 'not medically necessary.' What is the next appropriate step?

Answer: File an appeal with additional supporting documentation

When a prior authorization is denied, the provider should file a formal appeal with additional clinical documentation supporting medical necessity.

What is a 'peer-to-peer review' in the context of prior authorization?

Answer: A direct conversation between the treating physician and the payer's medical reviewer to discuss a denied authorization

A peer-to-peer review is a conversation between the treating physician and the payer's medical director to advocate for an authorization that has been denied.

Which of the following services typically DOES NOT require prior authorization?

Answer: Emergency appendectomy

Emergency services generally do not require prior authorization; payers recognize that emergencies cannot be anticipated.

What is the difference between a referral and a prior authorization?

Answer: A referral is a physician's order directing a patient to see a specialist; prior authorization is payer approval for a service

A referral is the physician's direction for a patient to see a specialist, while prior authorization is payer approval that a service is medically necessary.

In a managed care plan, a 'gatekeeper' is typically which of the following?

Answer: The primary care physician who manages referrals to specialists

In managed care plans (especially HMOs), the primary care physician acts as a gatekeeper, coordinating and authorizing referrals to specialists.

What should a billing specialist do when a prior authorization is approved but expires before the service is rendered?

Answer: Obtain a new or extended authorization before the service is rendered

If a prior authorization expires before the service is performed, a new or extended authorization must be obtained to ensure coverage.