CPAT Prior Authorization & Precertification

Question 1

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

Accepted Answer

Prior authorization

Answer

Retrospective review

Answer

Concurrent review

Answer

Discharge planning

Question 2

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

Accepted Answer

Precertification

Answer

Claim adjudication

Answer

Utilization review

Answer

Balance billing

Question 3

Which of the following services most commonly requires prior authorization?

Accepted Answer

Elective inpatient surgery

Answer

Annual wellness visit

Answer

Routine blood glucose test

Answer

Flu vaccination

Question 4

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

Accepted Answer

Patient's social media profile

Answer

ICD-10 diagnosis codes

Answer

CPT/HCPCS procedure codes

Answer

Provider NPI number

Question 5

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

Accepted Answer

Initiate a peer-to-peer review request

Answer

Bill the patient immediately

Answer

File a formal grievance with the state

Answer

Cancel the scheduled procedure

Question 6

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

Accepted Answer

ACA Section 2719

Answer

ERISA

Answer

HIPAA

Answer

CMS Conditions of Participation

Question 7

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

Accepted Answer

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

Answer

Guarantees full payment of the claim

Answer

Replaces the need for an Explanation of Benefits

Answer

Eliminates the patient's financial responsibility