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

Commercial HMO plans tend to have the most stringent prior authorization requirements because the gatekeeper model is central to their design.

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

Concurrent review evaluates whether a patient's continued inpatient stay is medically necessary, typically conducted daily or every few days.

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

Claims without required prior authorization are typically denied, and in many contracts, the provider cannot balance-bill the patient for the denied amount.

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

Medical necessity means the service is reasonable, necessary, and appropriate for the patient's diagnosis or condition based on evidence-based criteria.

Question 5

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

Accepted Answer

Insufficient clinical documentation to support medical necessity

Answer

Insufficient or incomplete clinical documentation is one of the most common reasons prior authorization requests are denied.

(CBCS) Certified Billing and Coding Specialist Practice Test

(CBCS) Certified Billing and Coding Specialist Practice Test

CBCS Prior Authorization and Referrals 2