Documentation & Record Management Flashcards

A patient's prior authorization is approved but the authorization letter lists an incorrect date of birth. The BEST course of action is to:

Answer: Contact the payer to correct the demographic error and request an amended authorization letter

An authorization with incorrect demographic data can cause claim denial; the payer must issue a corrected authorization letter before service.

In the context of prior authorization record management, 'chain of custody' refers to:

Answer: The documented trail of who accessed, transmitted, or modified an authorization record

Chain of custody documents every access or modification to a record, ensuring its integrity for audits and legal proceedings.

When a concurrent authorization review is conducted for an inpatient stay, clinical updates must be submitted:

Answer: At defined intervals throughout the stay to justify continued medical necessity

Concurrent reviews require ongoing clinical documentation submissions at intervals specified by the payer to support continued authorization.

Which action constitutes document falsification in the prior authorization process?

Answer: Altering a physician's clinical note to meet payer criteria without the physician's knowledge or consent

Altering a physician's clinical note without authorization constitutes fraud and is a federal offense under the False Claims Act.

A retrospective prior authorization is typically requested when:

Answer: A service was rendered in an emergency and authorization was not obtained before care was provided

Retrospective authorizations are submitted after emergency or urgent care when pre-service authorization was clinically impossible.

For a prior authorization tracking system to support internal audits effectively, it must include which of the following fields?

Answer: Authorization status history with timestamps for each status change

A complete status history with timestamps allows auditors to verify turnaround compliance and trace every decision in the authorization lifecycle.

Under 21st Century Cures Act provisions, which technology is being promoted to automate the exchange of prior authorization data between EHRs and payers?

Answer: FHIR-based APIs integrated with payer coverage decision support

The 21st Century Cures Act and CMS interoperability rules mandate FHIR APIs to enable real-time, EHR-embedded prior authorization workflows.