CPAT Prior Authorization & Precertification 2

Question 1

Which payer program uses a list of services that require authorization, often published in a payer's provider manual?

Accepted Answer

Prior authorization list (PAL)

Answer

Formulary

Answer

Explanation of Benefits (EOB)

Answer

Fee schedule

Question 2

A precertification is obtained for 5 inpatient days. The patient stays 8 days. What must the patient account technician do?

Accepted Answer

Request a concurrent review extension for the additional days

Answer

Submit a corrected claim for 8 days without notifying the payer

Answer

Discharge the patient on day 5

Answer

Apply the additional days to patient liability without payer notice

Question 3

Which coding set is most commonly used to communicate procedures when requesting prior authorization?

Accepted Answer

CPT/HCPCS codes

Answer

ICD-10-CM only

Answer

DRG codes

Answer

NDC codes

Question 4

What is the primary purpose of a Letter of Medical Necessity (LMN) in the authorization process?

Accepted Answer

To demonstrate that a requested service is clinically appropriate for the patient's condition

Answer

To inform the patient of their financial responsibility

Answer

To appeal a claim that has already been paid incorrectly

Answer

To transfer care to another provider network

Question 5

Under Medicare Advantage plans, which entity is responsible for issuing prior authorizations?

Accepted Answer

The Medicare Advantage plan (private insurer)

Answer

CMS directly

Answer

The Medicare Administrative Contractor (MAC)

Answer

The hospital's utilization management team

Question 6

A referral authorization differs from a prior authorization in that it:

Accepted Answer

Is issued by the primary care physician to allow the patient to see a specialist

Answer

Requires hospital inpatient admission

Answer

Only applies to Medicare beneficiaries

Answer

Covers emergency department visits automatically

Question 7

If a prior authorization is obtained but the patient's insurance coverage lapses before the service is rendered, the authorization is:

Accepted Answer

Voided, as authorization is contingent on active coverage at the time of service

Answer

Still valid because it was issued before the lapse

Answer

Transferable to the patient's new insurance plan

Answer

Extended automatically by the payer for 90 days