Documentation & Record Management Flashcards

Which of the following best describes 'prior authorization creep' in a documentation context?

Answer: A payer expanding the list of services requiring prior authorization over time

Prior authorization creep refers to payers progressively adding more services and drugs to their prior authorization required lists, increasing the administrative burden.

When documenting a phone-based prior authorization approval, which information must be captured to make the record legally defensible?

Answer: Approval reference number, date, time, agent name, and authorized service details

A verbal authorization is only defensible if the record captures the reference number, agent identity, timestamp, and specific service authorized.

An authorization record is flagged for a coding mismatch: the ICD-10 code on the authorization differs from the code on the claim. The MOST likely outcome is:

Answer: Claim denial or delay pending reconciliation of the diagnosis codes

Payer systems match authorization and claim data; a diagnosis code discrepancy triggers a denial or pends the claim for manual review.

Under the No Surprises Act, what documentation must providers give patients before rendering out-of-network services that may require prior authorization?

Answer: A Good Faith Estimate (GFE) of expected costs

The No Surprises Act requires a Good Faith Estimate for uninsured/self-pay patients and notice-and-consent forms for insured patients receiving out-of-network services.

Which clinical document is most commonly used to establish medical necessity for a specialty drug prior authorization?

Answer: Step therapy failure documentation showing inadequate response to formulary alternatives

Payers require step therapy failure documentation to confirm that lower-cost alternatives were tried and failed before approving high-cost specialty drugs.

A PACS specialist receives a payer portal error when uploading a clinical document. To maintain compliance, the specialist should:

Answer: Document the technical error, attempt an alternative submission method, and log all actions taken

Technical failures must be documented with timestamps and alternative submission attempts to demonstrate due diligence in the event of a dispute.

Which standard format is used for electronic submission of prior authorization requests between providers and payers?

Answer: ASC X12 278 Health Care Services Review

The ASC X12 278 transaction set is the federally mandated HIPAA standard for electronic prior authorization requests and responses.