CHAA Pre-Authorization and Referrals Management 3

Question 1

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

Accepted Answer

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

Answer

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

Question 2

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

Accepted Answer

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

Answer

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

Question 3

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

Accepted Answer

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

Answer

Gold card programs exempt providers who consistently demonstrate appropriate utilization.

Question 4

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

Accepted Answer

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

Answer

Each service may have its own authorization requirements.

Question 5

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

Accepted Answer

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

Answer

Access handles administrative aspects while UR provides clinical support.

CHAA - Certified Healthcare Access Associate Practice Test