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Prior Authorization & Precertification Flashcards

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  1. Which term describes the process of obtaining approval from a payer before a non-emergency medical service is rendered?

    Answer: Prior authorization

    Prior authorization requires advance payer approval before certain services are performed to confirm medical necessity and coverage.

  2. A patient needs an elective MRI. The hospital submits clinical documentation to the insurer before the procedure. This process is called:

    Answer: Precertification

    Precertification is the pre-service step where the provider notifies the payer and obtains approval before a scheduled procedure.

  3. Which of the following services most commonly requires prior authorization?

    Answer: Elective inpatient surgery

    Elective inpatient surgeries typically require prior authorization because of their high cost and the need to confirm medical necessity.

  4. What information is typically NOT required when submitting a prior authorization request?

    Answer: Patient's social media profile

    Prior authorization requests require clinical and billing information such as diagnosis codes, procedure codes, and provider identifiers—not personal social media data.

  5. When a payer denies a prior authorization request, the most appropriate initial step for the patient account technician is to:

    Answer: Initiate a peer-to-peer review request

    A peer-to-peer review allows the treating physician to speak directly with the payer's medical reviewer to appeal a denial based on clinical justification.

  6. Which federal law mandates that health plans provide timely decisions on prior authorization requests for urgent care?

    Answer: ACA Section 2719

    ACA Section 2719 requires health plans to have an effective appeals process and timely responses, including expedited reviews for urgent/emergent care prior authorizations.

  7. An authorization number received from a payer should be documented in the patient's account because it:

    Answer: Serves as proof of medical necessity review and links the claim to approved services

    The authorization number ties the submitted claim to the payer's pre-approved service, supporting clean claim submission and reducing denial risk.