Prior Authorizations and Referral Management Flashcards

A physician orders an MRI for a patient. Before scheduling the exam, the medical administrative assistant contacts the insurance company for approval. This process is called:

Answer: Obtaining prior authorization

Prior authorization (pre-auth or pre-approval) is the payer's requirement to approve certain services before they are rendered, confirming medical necessity and coverage. A superbill is a billing document, coordination of benefits applies when a patient has two insurers, and an EOB is a statement sent after a claim is processed.

When a prior authorization request is denied by the payer, what is the MOST appropriate next step for the medical administrative assistant?

Answer: Notify the treating provider and initiate the payer's formal appeal process

A denial is not always final. The correct step is to inform the provider, who can supply additional clinical documentation supporting medical necessity as part of a formal payer appeal. Proceeding without authorization or billing the patient without disclosure exposes the practice to legal and financial risk.

Which of the following information is typically required when submitting a prior authorization request to an insurance company?

Answer: Provider's NPI, procedure codes (CPT), diagnosis codes (ICD), and clinical justification

Payers evaluate prior authorization requests using clinical and administrative data: the ordering provider's NPI (National Provider Identifier), CPT codes for the requested service, ICD-10 diagnosis codes, and documentation justifying medical necessity. Financial or accreditation information is not part of this process.

A primary care physician directs a patient to see a cardiologist. The medical administrative assistant's responsibility in this workflow is to:

Answer: Generate and transmit the referral order to the specialist's office and verify it was received

The administrative assistant is responsible for processing the referral order — sending the physician-generated referral to the specialist, confirming receipt, and often verifying that the referral is authorized by the patient's insurance plan before the appointment occurs.

A prior authorization was approved on March 1 with a 90-day validity window. The patient's procedure has not yet been scheduled. What must the administrative assistant do?

Answer: Ensure the procedure is scheduled and performed before May 30, or obtain re-authorization

Prior authorizations are valid for a defined period (commonly 60–90 days, depending on the payer). Services must be rendered within that window. If the authorization expires before the service is performed, the practice must request re-authorization to ensure coverage.

Which insurance plan type most commonly requires patients to obtain a referral from their PCP before seeing an out-of-network specialist?

Answer: Health Maintenance Organization (HMO)

HMO plans use a gatekeeper model in which the PCP must issue a referral for specialist care. Out-of-network specialist visits are generally not covered at all under an HMO without a referral. PPOs and indemnity plans allow direct specialist access without referrals.