CBCS Prior Authorization and Referrals 3

Question 1

Which federal law requires most insurers to respond to prior authorization requests for urgent services within a specific timeframe?

Accepted Answer

No federal law currently exists for all plans

Answer

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.

Question 2

What is the purpose of an 'authorization number'?

Accepted Answer

A unique identifier assigned by the payer confirming that a service has been authorized for coverage

Answer

An authorization number is a unique tracking number issued by the payer confirming approval of a requested service.

Question 3

A patient with a PPO plan sees a specialist without a referral. What is likely to happen?

Accepted Answer

The service may be covered but potentially at a higher cost-sharing rate depending on plan rules

Answer

PPO plans generally allow self-referrals to specialists but may require prior authorization for certain services; cost-sharing may vary.

Question 4

What is 'step therapy' and why is it relevant to prior authorization?

Accepted Answer

A treatment protocol requiring patients to try less costly or less intensive treatments before a more expensive one is approved

Answer

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.

Question 5

Which of the following is true about authorizations for durable medical equipment (DME)?

Accepted Answer

Medicare requires prior authorization for certain high-cost DME items

Answer

Medicare has a Prior Authorization Program for certain high-cost or frequently abused DME items to prevent unnecessary utilization.

(CBCS) Certified Billing and Coding Specialist Practice Test

(CBCS) Certified Billing and Coding Specialist Practice Test

CBCS Prior Authorization and Referrals 3