Pre-Authorization and Referrals Management Flashcards

What happens to financial responsibility if pre-authorization is not obtained before an elective service?

Answer: The patient may be responsible for the entire cost if insurance denies the claim

Without required pre-authorization, the insurer may deny the claim, potentially leaving the patient responsible.

How should patient access manage authorizations for recurring treatments like physical therapy?

Answer: Track authorized visits, monitor approaching limits, and proactively request re-authorization before visits are exhausted

Recurring authorizations have visit limits and expiration dates requiring proactive monitoring.

What is a 'gold card' or prior authorization exemption program?

Answer: It exempts providers with high approval rates from certain authorization requirements, reducing administrative burden

Gold card programs exempt providers who consistently demonstrate appropriate utilization.

When multiple services are scheduled for the same day, how should authorizations be managed?

Answer: Each service may need its own authorization, verified and obtained independently

Each service may have its own authorization requirements.

What role does the utilization review nurse play in pre-authorization, and how does patient access collaborate?

Answer: UR provides clinical documentation and medical necessity justification that patient access coordinates into the submission and tracking process

Access handles administrative aspects while UR provides clinical support.

A patient needs an urgent MRI but the payer's authorization line is closed after hours. What should patient access do?

Answer: Document the urgency, proceed under the urgent authorization protocol, and submit the request next business day

Urgent clinical needs should not be delayed for administrative reasons.