CPAT Prior Authorization & Precertification 3

Question 1

Which term describes the retrospective review by a payer of services already rendered to determine if they were medically necessary?

Accepted Answer

Post-service (retrospective) review

Answer

Precertification

Answer

Prospective review

Answer

Concurrent review

Question 2

When a provider fails to obtain required prior authorization and the payer denies the claim, who typically bears financial responsibility?

Accepted Answer

The provider, for failing to follow payer requirements

Answer

The payer, by default policy

Answer

The patient, through balance billing

Answer

The attending physician personally

Question 3

Which of the following best describes an 'expedited' prior authorization request?

Accepted Answer

An urgent request required when a delay could seriously jeopardize the patient's health

Answer

A standard request submitted electronically

Answer

A retrospective review of already-completed services

Answer

A routine elective procedure request with a 14-day turnaround

Question 4

HIPAA's Administrative Simplification provisions support prior authorization by:

Accepted Answer

Standardizing electronic transaction formats that can be used for authorization requests

Answer

Eliminating the need for prior authorization for all Medicare services

Answer

Requiring all payers to approve every authorization request submitted

Answer

Mandating prior authorization turnaround within 24 hours for all plans

Question 5

The ASC X12 278 transaction set is used in healthcare to:

Accepted Answer

Transmit electronic prior authorization requests and responses

Answer

Submit claims to payers for reimbursement

Answer

Verify patient eligibility and benefits

Answer

Send electronic remittance advice to providers

Question 6

A patient's prior authorization is approved for a specific CPT code, but the physician performs a slightly different procedure. What risk does this create?

Accepted Answer

A claim denial because the rendered service does not match the authorized service

Answer

No risk, as authorizations cover all procedures for that visit

Answer

Automatic upgrade of the authorization to cover the new procedure

Answer

Requirement to discharge the patient immediately

Question 7

Which action best supports compliance when tracking prior authorization expiration dates?

Accepted Answer

Maintaining a tickler system or authorization tracking log with expiration alerts

Answer

Relying on the physician's office to monitor authorization validity

Answer

Submitting claims regardless of authorization expiration and appealing denials

Answer

Requesting new authorizations only after a denial is received