CBCS Prior Authorization and Referrals 2

Question 1

Which payer type typically requires the most stringent prior authorization requirements?

Accepted Answer

Commercial HMO plans

Answer

Medicare fee-for-service

Answer

Medicaid managed care plans

Answer

Workers' compensation payers

Question 2

What is the purpose of 'concurrent review' in utilization management?

Accepted Answer

To monitor ongoing inpatient care to verify continued medical necessity for continued stay

Answer

To review services after they have been completed

Answer

To approve services before they are performed

Answer

To review a provider's billing patterns for compliance

Question 3

What is the consequence of billing for a service that required prior authorization but was not obtained?

Accepted Answer

The claim will likely be denied, and the provider may not be able to bill the patient

Answer

The claim is automatically resubmitted with a corrected authorization

Answer

The patient is responsible for the full cost of the service

Answer

The payer pays at a reduced rate automatically

Question 4

What does the term 'medical necessity' mean in the context of insurance coverage?

Accepted Answer

Services that are reasonable and necessary for diagnosis or treatment of an illness or injury based on established clinical guidelines

Answer

Any service a physician deems appropriate for a patient

Answer

Any service covered under the patient's benefit plan

Answer

Services performed in an acute care hospital setting

Question 5

Which of the following is a common reason for prior authorization denial?

Accepted Answer

Insufficient clinical documentation to support medical necessity

Answer

The provider is in-network with the payer

Answer

The requested service is listed as covered in the patient's benefit plan

Answer

The patient has met their annual deductible

Question 6

What is a 'letter of medical necessity' (LMN)?

Accepted Answer

A physician's detailed statement explaining why a specific treatment is medically necessary for a patient

Answer

A form signed by the patient authorizing treatment

Answer

A payer's written approval for a service

Answer

A legal document filed with the state insurance commissioner

Question 7

In which scenario would a 'retrospective review' occur?

Accepted Answer

After emergency services are provided and stabilization has occurred

Answer

Before a planned elective procedure

Answer

During an inpatient stay on a daily basis

Answer

When a patient requests a referral to a specialist

Question 8

When should a billing specialist begin tracking a prior authorization request?

Accepted Answer

Immediately upon submission of the authorization request

Answer

After the service has been performed and billed

Answer

After the payer issues a decision

Answer

Only after a denial is received