PACS PACS Clinical Review & Utilization Management 2

Question 1

What does 'medical necessity' generally mean in the context of prior authorization criteria?

Accepted Answer

Services that are appropriate, consistent with the diagnosis, and in accordance with accepted standards of medical practice

Answer

Medical necessity refers to services that are appropriate, consistent with the patient's diagnosis, and in accordance with accepted standards of medical practice.

Question 2

A clinician reviewing a prior authorization request for a high-cost biologic drug should primarily assess which of the following?

Accepted Answer

Whether the patient has tried and failed clinically appropriate alternative therapies as required by step therapy

Answer

For high-cost biologics, the clinical reviewer primarily assesses whether the patient has tried and failed appropriate step therapy alternatives before approving the biologic.

Question 3

What is the term for a prior authorization decision made BEFORE the patient receives the requested service or medication?

Accepted Answer

Prospective review (pre-authorization)

Answer

A prospective review, also called pre-authorization, is a utilization management decision made before the patient receives the requested service or medication.

Question 4

Which of the following criteria is most commonly evaluated during a clinical review of a prior authorization request for an MRI?

Accepted Answer

Whether the patient's symptoms and clinical history meet evidence-based indications for the imaging study

Answer

Clinical review of an MRI authorization evaluates whether the patient's symptoms and clinical history meet the evidence-based indications established in UM criteria guidelines.

Question 5

What is a 'non-covered service' in the context of prior authorization?

Accepted Answer

A service explicitly excluded from coverage under the patient's health plan benefits

Answer

A non-covered service is one that is explicitly excluded from a patient's health plan benefits, and prior authorization cannot override benefit exclusions.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS PACS Clinical Review & Utilization Management 2