CPAT Prior Authorization & Precertification 1 — Questions and Answers
Question 1: Which term describes the process of obtaining approval from a payer before a non-emergency medical service is rendered?
- Retrospective review
- Prior authorization (Correct answer)
- Concurrent review
- Discharge planning
Correct answer: Prior authorization
Prior authorization requires advance payer approval before certain services are performed to confirm medical necessity and coverage.
Question 2: A patient needs an elective MRI. The hospital submits clinical documentation to the insurer before the procedure. This process is called:
- Claim adjudication
- Utilization review
- Precertification (Correct answer)
- Balance billing
Correct answer: Precertification
Precertification is the pre-service step where the provider notifies the payer and obtains approval before a scheduled procedure.
Question 3: Which of the following services most commonly requires prior authorization?
- Annual wellness visit
- Routine blood glucose test
- Elective inpatient surgery (Correct answer)
- Flu vaccination
Correct answer: Elective inpatient surgery
Elective inpatient surgeries typically require prior authorization because of their high cost and the need to confirm medical necessity.
Question 4: What information is typically NOT required when submitting a prior authorization request?
- ICD-10 diagnosis codes
- CPT/HCPCS procedure codes
- Provider NPI number
- Patient's social media profile (Correct answer)
Correct 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.
Question 5: When a payer denies a prior authorization request, the most appropriate initial step for the patient account technician is to:
- Bill the patient immediately
- File a formal grievance with the state
- Initiate a peer-to-peer review request (Correct answer)
- Cancel the scheduled procedure
Correct 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.
Question 6: Which federal law mandates that health plans provide timely decisions on prior authorization requests for urgent care?
- ERISA
- HIPAA
- ACA Section 2719 (Correct answer)
- CMS Conditions of Participation
Correct 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.
Question 7: An authorization number received from a payer should be documented in the patient's account because it:
- Guarantees full payment of the claim
- Serves as proof of medical necessity review and links the claim to approved services (Correct answer)
- Replaces the need for an Explanation of Benefits
- Eliminates the patient's financial responsibility
Correct 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.
CPAT Prior Authorization & Precertification 1
Which term describes the process of obtaining approval from a payer before a non-emergency medical service is rendered?