CBCS Prior Authorization and Referrals

Question 1

What is the primary purpose of prior authorization in healthcare?

Accepted Answer

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

Answer

To allow patients to self-refer to specialists

Answer

To ensure the provider is credentialed with the payer

Answer

To notify the patient of their financial responsibility

Question 2

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

Accepted Answer

Clinical notes supporting medical necessity

Answer

A signed patient HIPAA authorization

Answer

The patient's complete billing history

Answer

The provider's facility license

Question 3

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

Accepted Answer

File an appeal with additional supporting documentation

Answer

Immediately bill the patient for the full amount

Answer

Submit the claim anyway without authorization

Answer

Refer the patient to a different provider

Question 4

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

Accepted Answer

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

Answer

A quality review of a physician's practice conducted by another physician

Answer

A review of a patient's records by two different physicians simultaneously

Answer

A second opinion requested by the insurance company

Question 5

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

Accepted Answer

Emergency appendectomy

Answer

Elective inpatient surgery

Answer

MRI for a new complaint

Answer

Specialty biologics

Question 6

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

Accepted Answer

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

Answer

They are the same process with different names

Answer

A referral is required only for inpatient care; prior authorization is for outpatient services

Answer

A referral is given by the patient; prior authorization is requested by the physician

Question 7

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

Accepted Answer

The primary care physician who manages referrals to specialists

Answer

The insurance company's medical director

Answer

The utilization management department

Answer

The patient's case manager

Question 8

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

Accepted Answer

Obtain a new or extended authorization before the service is rendered

Answer

Proceed with the service and appeal if denied

Answer

Bill the patient directly for the service

Answer

Use the expired authorization number on the claim