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

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

Question 2

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

Accepted Answer

Clinical notes supporting medical necessity

Answer

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.

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

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

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 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.

Question 5

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

Accepted Answer

Emergency appendectomy

Answer

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

(CBCS) Certified Billing and Coding Specialist Practice Test

(CBCS) Certified Billing and Coding Specialist Practice Test

CBCS Prior Authorization and Referrals