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

A retrospective review occurs after services are provided, when the payer evaluates whether those services met medical necessity criteria for coverage.

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

When a provider neglects to obtain a required authorization, the payer may deny the claim and the provider—not the patient—is generally responsible for the resulting write-off.

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

An expedited authorization is required for urgent cases where the standard review timeline would harm the patient, and payers must respond faster than for routine requests.

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

HIPAA's administrative simplification rules establish standard electronic transaction sets (such as the 278 transaction) that streamline the submission of authorization requests.

Question 5

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

Accepted Answer

Transmit electronic prior authorization requests and responses

Answer

The X12 278 transaction is the HIPAA-standard electronic format specifically designed for health care services review (prior authorization) requests and responses.

CPAT - Certified Patient Account Technician Practice Test

CPAT - Certified Patient Account Technician Practice Test

CPAT Prior Authorization & Precertification 3