PACS Appeals & Grievance Management Flashcards
6 cards from real PACS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 PACS Appeals & Grievance Management flashcards as text
What does 'exhaustion of internal remedies' mean in the context of prior authorization appeals?
Answer: The member has completed all required internal appeal levels before seeking external review
Exhaustion of internal remedies means the member has gone through all internal appeal levels required by the plan before they are eligible for external review.
Under ERISA, employees in self-funded employer health plans who are denied prior authorization have the right to appeal their claim, but which external review option is typically NOT available to them?
Answer: State-mandated external independent review
ERISA preempts state insurance laws for self-funded plans, so state-mandated external independent review rights generally do not apply to ERISA-governed plans.
A prior authorization appeal is overturned in the patient's favor by an external reviewer. What is the health plan's obligation?
Answer: The plan must honor the external reviewer's decision and authorize the requested service
External reviewer decisions in favor of the patient are binding on the health plan, which must authorize the requested service.
Which of the following best describes an 'expedited appeal' for prior authorization?
Answer: A fast-track appeal process used when waiting for a standard review could seriously jeopardize the patient's health
An expedited appeal is a fast-track review used when the standard timeframe could seriously jeopardize the patient's health or ability to regain maximum function.
When submitting a prior authorization appeal, which piece of information is LEAST relevant to include?
Answer: The patient's prior pharmacy co-pay history
A patient's prior pharmacy co-pay history has no bearing on the clinical or coverage arguments needed to overturn a prior authorization denial.
In Medicaid managed care, a member who disagrees with a prior authorization denial has the right to request a 'State Fair Hearing.' Who conducts this hearing?
Answer: A neutral administrative law judge or hearing officer appointed by the state
State Fair Hearings in Medicaid are conducted by a neutral administrative law judge or hearing officer appointed by the state agency, not the MCO.
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