Technology & Information Systems in Prior Authorization Flashcards

What does HL7 FHIR stand for, and why is it significant in prior authorization?

Answer: Health Level 7 Fast Healthcare Interoperability Resources; enables structured real-time data exchange for PA between systems

HL7 FHIR (Fast Healthcare Interoperability Resources) is a data exchange standard that enables structured, real-time sharing of healthcare information, including prior authorization data, between payers and providers.

What is 'gold carding' in the context of prior authorization programs?

Answer: Exempting high-performing providers from PA requirements based on their consistently high approval history

Gold carding (also called provider exemption programs) exempts providers with consistently high PA approval rates from submitting PA requests for specific services, reducing administrative burden while preserving oversight.

What is the purpose of a 'PA attachment' in electronic prior authorization transactions?

Answer: Clinical documentation submitted electronically alongside the PA request to support medical necessity

PA attachments are electronic clinical documents — such as medical records, lab results, or clinical notes — submitted alongside a PA request to provide evidence supporting medical necessity.

Which of the following best describes the NCPDP SCRIPT standard's role in pharmacy prior authorization?

Answer: It provides a standardized electronic message format for pharmacy PA requests and responses between prescribers and payers

The NCPDP SCRIPT standard provides a standardized electronic message format that enables prescribers and payers to exchange pharmacy prior authorization requests, clinical information, and responses efficiently.

What HIPAA rule applies to electronic prior authorization systems that create, maintain, or transmit protected health information (PHI)?

Answer: HIPAA Security Rule, requiring administrative, physical, and technical safeguards specifically for electronic PHI (ePHI)

The HIPAA Security Rule (45 CFR Part 164) requires covered entities and business associates to implement administrative, physical, and technical safeguards to protect electronic PHI processed or stored in PA systems.

What is 'auto-authorization' (auto-auth) in the context of prior authorization technology systems?

Answer: Automatic approval of PA requests that meet predefined clinical criteria without requiring manual clinical review

Auto-authorization is a PA system feature that automatically approves requests when submitted clinical data meets predefined criteria, eliminating manual review for straightforward cases and reducing turnaround time.

Which metric is most commonly used to measure the effectiveness of electronic prior authorization technology adoption?

Answer: ePA adoption rate — the percentage of total PA requests submitted electronically versus manually or by phone/fax

The ePA adoption rate measures the proportion of PA requests submitted electronically versus manually, serving as a key indicator of technology adoption and the degree of administrative efficiency achieved.