Practice Test Geeks(PACS) Prior Authorization Certified Specialist Practice Test
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PACS Clinical Review & Utilization 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 Clinical Review & Utilization Management flashcards as text

  1. What is the primary purpose of utilization management (UM) in the prior authorization process?

    Answer: To ensure that healthcare services are medically necessary, appropriate, and cost-effective

    Utilization management ensures that healthcare services meet criteria for medical necessity, appropriateness, and cost-effectiveness before authorization is granted.

  2. Which organization is widely known for developing evidence-based clinical criteria used in utilization management and prior authorization decisions?

    Answer: InterQual (Change Healthcare) and Milliman Care Guidelines

    InterQual (Change Healthcare) and Milliman Care Guidelines are the most widely used evidence-based clinical criteria sets in utilization management and prior authorization decisions.

  3. What is 'step therapy' in the context of prior authorization for medications?

    Answer: A protocol requiring patients to try lower-cost or first-line treatments before a preferred or specialty drug is approved

    Step therapy, or 'fail-first' protocols, requires patients to try specified first-line or lower-cost treatments before a health plan will authorize coverage for a more expensive alternative.

  4. In utilization management, what is a 'concurrent review'?

    Answer: A review of a patient's care while they are currently receiving inpatient services

    Concurrent review evaluates the medical necessity of continued inpatient care while the patient is currently admitted and receiving services.

  5. Which federal law requires that mental health and substance use disorder benefits in employer-sponsored plans be provided at parity with medical/surgical benefits?

    Answer: The Mental Health Parity and Addiction Equity Act (MHPAEA)

    The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that mental health and substance use disorder benefits be provided at parity with medical/surgical benefits.

  6. What is a 'formulary exception' request in the context of prescription drug prior authorization?

    Answer: A request for coverage of a non-formulary drug when a formulary alternative is inappropriate for the patient

    A formulary exception requests coverage for a non-formulary drug when the available formulary alternatives are clinically inappropriate or contraindicated for that specific patient.

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Sources & references

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  1. priorauthtraining.org — Eligibility, score validity, test delivery, retake fee, retake policy, score release, test dates, fees · verified Oct 2026