PACS PACS Appeals & Grievance Management

Question 1

What is the first step a patient should take after receiving a prior authorization denial from their insurance plan?

Accepted Answer

Request an internal appeal with the insurance company

Answer

File a complaint with the state insurance commissioner

Answer

Contact the prescribing physician to change the medication

Answer

Submit a grievance to the Centers for Medicare & Medicaid Services

Question 2

Under the ACA, how many days does a health plan generally have to respond to an expedited internal appeal for urgent care prior authorization?

Accepted Answer

72 hours

Answer

30 days

Answer

60 days

Answer

14 days

Question 3

What is an Independent Review Organization (IRO) in the context of prior authorization appeals?

Accepted Answer

A state-licensed external entity that conducts independent medical necessity reviews

Answer

An internal committee within the insurance company that reviews denials

Answer

A federal agency that oversees all insurance disputes

Answer

A provider advocacy group that supports denied claims

Question 4

Which document is most critical to include when submitting a prior authorization appeal for a denied specialty medication?

Accepted Answer

Physician's letter of medical necessity with clinical evidence

Answer

Patient's payment history with the pharmacy

Answer

Insurance plan's formulary document

Answer

Patient's signed consent for treatment

Question 5

What is the standard timeframe for a health plan to resolve a standard internal appeal for a prior authorization denial under federal guidelines?

Accepted Answer

30 days

Answer

7 days

Answer

60 days

Answer

90 days

Question 6

Which of the following best describes a 'grievance' in the context of health plan administration?

Accepted Answer

A complaint about the quality of care or plan services, distinct from a coverage appeal

Answer

A formal request to authorize a new medication

Answer

An inquiry about a patient's eligibility status

Answer

A request for a second medical opinion