CHAA Pre-Authorization and Referrals Management 2

Question 1

What is the key difference between a pre-authorization and a referral?

Accepted Answer

Pre-authorization is insurance approval confirming medical necessity and coverage; a referral is a PCP order directing the patient to a specialist

Answer

They are the same thing

Answer

A referral is more important

Answer

Pre-authorizations are only for hospital stays

Question 2

A pre-authorization request has been denied. What options are available?

Accepted Answer

File a peer-to-peer review, a formal appeal with additional documentation, or an expedited appeal for urgent situations

Answer

Nothing can be done

Answer

Only the patient can appeal

Answer

Denials are final

Question 3

What information is required when submitting a pre-authorization request?

Accepted Answer

Patient demographics, insurance information, diagnosis codes, procedure codes, clinical documentation, and provider information

Answer

Only patient name and insurance number

Answer

Only a verbal request

Answer

The patient's payment history

Question 4

A patient's PCP referral has expired. They're at the facility for their specialist appointment. What should patient access do?

Accepted Answer

Contact the PCP's office for a new referral, inform the patient, and coordinate with the specialist on timing

Answer

Proceed without a valid referral

Answer

Cancel and send the patient home

Answer

Tell the patient insurance won't cover it

Question 5

What is retrospective authorization, and when is it used?

Accepted Answer

Authorization obtained after services are rendered, typically for emergencies or when prior authorization couldn't be obtained in time

Answer

Authorization before a planned service

Answer

A type of insurance plan

Answer

It eliminates authorization needs

Question 6

How do electronic prior authorization (ePA) systems benefit patient access?

Accepted Answer

They automate requests and responses, reducing processing time, errors, and providing real-time status updates

Answer

They eliminate clinical documentation needs

Answer

Only for pharmacy authorizations

Answer

More time-consuming than phone-based methods