Pre-Authorization and Referrals Management Flashcards
6 cards from real CHAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Pre-Authorization and Referrals Management flashcards as text
What is the key difference between a pre-authorization and a referral?
Answer: Pre-authorization is insurance approval confirming medical necessity and coverage; a referral is a PCP order directing the patient to a specialist
Pre-authorization confirms insurance coverage while a referral directs a patient between providers.
A pre-authorization request has been denied. What options are available?
Answer: File a peer-to-peer review, a formal appeal with additional documentation, or an expedited appeal for urgent situations
Pre-authorization denials can be challenged through multiple appeal mechanisms.
What information is required when submitting a pre-authorization request?
Answer: Patient demographics, insurance information, diagnosis codes, procedure codes, clinical documentation, and provider information
Pre-authorization requires comprehensive patient, insurance, clinical, and provider information.
A patient's PCP referral has expired. They're at the facility for their specialist appointment. What should patient access do?
Answer: Contact the PCP's office for a new referral, inform the patient, and coordinate with the specialist on timing
An expired referral requires proactive resolution while minimizing care disruption.
What is retrospective authorization, and when is it used?
Answer: Authorization obtained after services are rendered, typically for emergencies or when prior authorization couldn't be obtained in time
Retrospective authorization is sought after services are provided in emergencies or urgent situations.
How do electronic prior authorization (ePA) systems benefit patient access?
Answer: They automate requests and responses, reducing processing time, errors, and providing real-time status updates
ePA systems streamline the process through automation, faster responses, and real-time tracking.