CMAA Prior Authorizations and Referral Management

Question 1

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:

Accepted Answer

Obtaining prior authorization

Answer

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.

Question 2

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

Accepted Answer

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

Answer

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.

Question 3

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

Accepted Answer

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

Answer

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.

Question 4

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

Accepted Answer

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

Answer

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.

Question 5

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?

Accepted Answer

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

Answer

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.

CMAA - Certified Medical Administrative Assistant Practice Test

CMAA - Certified Medical Administrative Assistant Practice Test

CMAA Prior Authorizations and Referral Management