CHAA Pre-Authorization and Referrals Management 2 — Questions and Answers
Question 1: What is the key difference between a pre-authorization and a referral?
- They are the same thing
- Pre-authorization is insurance approval confirming medical necessity and coverage; a referral is a PCP order directing the patient to a specialist (Correct answer)
- A referral is more important
- Pre-authorizations are only for hospital stays
Correct 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.
Pre-authorization is the insurer's advance approval confirming medical necessity and coverage. A referral is a physician's recommendation directing a patient to another provider. Some plans (especially HMOs) require both. Patient access must verify which apply for each plan, provider, and service combination.
Question 2: A pre-authorization request has been denied. What options are available?
- Nothing can be done
- File a peer-to-peer review, a formal appeal with additional documentation, or an expedited appeal for urgent situations (Correct answer)
- Only the patient can appeal
- Denials are final
Correct 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.
Options include peer-to-peer review (physician discusses case with payer's reviewer), formal written appeal with additional documentation, expedited appeal for urgent cases, and external review by an independent third party. Patient access facilitates by tracking statuses, coordinating documentation, and meeting filing deadlines.
Question 3: What information is required when submitting a pre-authorization request?
- Only patient name and insurance number
- Patient demographics, insurance information, diagnosis codes, procedure codes, clinical documentation, and provider information (Correct answer)
- Only a verbal request
- The patient's payment history
Correct 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 complete submission includes patient demographics, member ID, subscriber/group information, requesting and rendering provider NPIs, CPT/HCPCS codes, ICD-10 diagnosis codes, clinical documentation, letter of medical necessity, and expected service dates. Incomplete submissions are the leading cause of delays.
Question 4: A patient's PCP referral has expired. They're at the facility for their specialist appointment. What should patient access do?
- Proceed without a valid referral
- Contact the PCP's office for a new referral, inform the patient, and coordinate with the specialist on timing (Correct answer)
- Cancel and send the patient home
- Tell the patient insurance won't cover it
Correct 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.
The representative should verify referral status in the payer's system, contact the PCP for an updated referral (many can issue electronic referrals immediately), inform the patient of the situation and expected timeline, coordinate with the specialist's office, and document all actions. Pre-registration should catch these issues earlier.
Question 5: What is retrospective authorization, and when is it used?
- Authorization before a planned service
- Authorization obtained after services are rendered, typically for emergencies or when prior authorization couldn't be obtained in time (Correct answer)
- A type of insurance plan
- It eliminates authorization needs
Correct 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.
Retro authorization applies for emergency admissions, urgent situations where clinical need couldn't wait, system failures, and observation-to-inpatient transitions. Most payers allow 24-72 hours for submission. Missing deadlines can result in denials.
Question 6: How do electronic prior authorization (ePA) systems benefit patient access?
- They eliminate clinical documentation needs
- They automate requests and responses, reducing processing time, errors, and providing real-time status updates (Correct answer)
- Only for pharmacy authorizations
- More time-consuming than phone-based methods
Correct 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.
Benefits include reduced processing time, automated clinical data extraction from EHRs, real-time tracking, reduced administrative burden, fewer manual errors, standardized formats, and audit trails. Organizations report 60-80% reduction in processing time.
CHAA Pre-Authorization and Referrals Management 2
What is the key difference between a pre-authorization and a referral?