Documentation & Record Management Flashcards

A payer requests additional clinical documentation during the prior authorization review process. This request is commonly called a(n):

Answer: Additional Development Request (ADR)

An Additional Development Request (ADR) is a formal payer request for supplementary clinical or administrative documentation to complete the review.

Which data element in an electronic prior authorization (ePA) transaction most commonly maps to ASC X12 278 segment NM1?

Answer: Subscriber or patient name

The NM1 loop in the X12 278 transaction carries name information for the subscriber, patient, provider, or other entities.

For Medicare Advantage plans, prior authorization documentation must typically be maintained by the provider for at least:

Answer: 10 years after the date of service

CMS requires Medicare Advantage plan providers to retain records for 10 years to support potential audits and overpayment reviews.

A PACS specialist must document a 'same or similar' equipment check before authorizing durable medical equipment (DME). This check verifies that:

Answer: The patient does not already have an active authorization for identical or comparable equipment

Medicare and most payers prohibit duplicate authorization for same or similar equipment to prevent duplicate billing.

When a prior authorization is obtained for a procedure that later changes in scope, the PACS specialist should:

Answer: Document the change and submit a new or amended authorization request

A material change in procedure type or scope voids the original authorization; a new request must document the clinical change.

Which document type serves as the primary source of truth when auditing whether a prior authorization was required for a service?

Answer: The payer's benefit grid or coverage determination policy

The payer's coverage determination policy (benefit grid) defines which services require prior authorization and under what conditions.

A prior authorization specialist encounters a fax containing PHI that was sent to the wrong number. Under HIPAA, the first required action is to:

Answer: Document the misdirected fax and conduct a breach risk assessment

HIPAA's Breach Notification Rule requires a four-factor risk assessment to determine whether notification obligations are triggered.