PACS PACS Appeals & Grievance Management 3

Question 1

What does 'exhaustion of internal remedies' mean in the context of prior authorization appeals?

Accepted Answer

The member has completed all required internal appeal levels before seeking external review

Answer

The patient has used all available medications on the formulary

Answer

The insurance company has reviewed the claim multiple times

Answer

The provider has submitted all required clinical documents

Question 2

Under ERISA, employees in self-funded employer health plans who are denied prior authorization have the right to appeal their claim, but which external review option is typically NOT available to them?

Accepted Answer

State-mandated external independent review

Answer

Filing an internal appeal with the plan

Answer

Requesting a peer-to-peer review

Answer

Providing additional clinical documentation

Question 3

A prior authorization appeal is overturned in the patient's favor by an external reviewer. What is the health plan's obligation?

Accepted Answer

The plan must honor the external reviewer's decision and authorize the requested service

Answer

The plan can choose whether to honor the external reviewer's decision

Answer

The plan must re-review the decision internally before complying

Answer

The plan can appeal the external reviewer's decision to a federal court

Question 4

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

Accepted Answer

A fast-track appeal process used when waiting for a standard review could seriously jeopardize the patient's health

Answer

An appeal filed by the insurance company to reverse a previously approved authorization

Answer

An appeal that is processed within 60 days due to administrative backlog

Answer

An appeal handled directly by the treating nurse without physician involvement

Question 5

When submitting a prior authorization appeal, which piece of information is LEAST relevant to include?

Accepted Answer

The patient's prior pharmacy co-pay history

Answer

The specific denial reason cited by the insurer

Answer

Clinical guidelines supporting medical necessity

Answer

The treating physician's credentials and specialty

Question 6

In Medicaid managed care, a member who disagrees with a prior authorization denial has the right to request a 'State Fair Hearing.' Who conducts this hearing?

Accepted Answer

A neutral administrative law judge or hearing officer appointed by the state

Answer

The managed care organization's internal appeals board

Answer

An independent arbitrator hired by the MCO

Answer

The prescribing physician's office