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

Payers publish a prior authorization list identifying exactly which services, drugs, or procedures require advance approval before coverage applies.

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

A concurrent review extension must be requested when the patient's stay exceeds the originally authorized length to maintain coverage for additional days.

Question 3

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

Accepted Answer

CPT/HCPCS codes

Answer

CPT and HCPCS codes identify the specific procedures requested, which payers use to evaluate authorization criteria.

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

An LMN is written by the physician to justify that the requested service is medically necessary, supporting the authorization request.

Question 5

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

Accepted Answer

The Medicare Advantage plan (private insurer)

Answer

Medicare Advantage plans are administered by private insurers who set their own coverage policies, including prior authorization requirements, within CMS guidelines.

CPAT - Certified Patient Account Technician Practice Test

CPAT - Certified Patient Account Technician Practice Test

CPAT Prior Authorization & Precertification 2