Technology & Information Systems in Prior Authorization Flashcards

What is the purpose of the HL7 Da Vinci Prior Authorization Support (PAS) FHIR Implementation Guide?

Answer: To define FHIR-based workflows enabling providers to submit and manage PA requests directly from their EHR to payer systems

The Da Vinci PAS FHIR Implementation Guide defines standardized FHIR-based workflows that enable providers to submit, track, and manage prior authorization requests directly from EHR systems, improving interoperability with payer systems.

Step therapy requirements managed through PA systems require providers to document what before a higher-cost treatment can be authorized?

Answer: That the patient tried and failed clinically appropriate lower-cost or preferred treatments before the alternative is authorized

Step therapy (fail-first) protocols managed through PA systems require providers to document that a patient has tried and not responded to first-line treatments before a payer will authorize a more expensive alternative therapy.

What is the primary role of audit logging in prior authorization information systems?

Answer: To create a traceable, time-stamped record of all PA transactions for compliance, fraud detection, and accountability

Audit logging in PA systems creates a comprehensive, traceable record of all transactions — including submissions, reviews, decisions, and appeals — essential for regulatory compliance, fraud detection, and organizational accountability.

Under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), what are the required PA decision timeframes for impacted payers?

Answer: 72 hours for urgent (expedited) requests and 7 calendar days for standard requests

CMS-0057-F requires impacted payers to provide PA decisions within 72 hours for urgent (expedited) requests and 7 calendar days for standard requests, and to include specific reasons when requests are denied.

What is the purpose of a Prior Authorization Requirements, Documentation, and Decision (PARDD) API in PA technology systems?

Answer: To enable providers to query a payer's PA requirements, submit clinical documentation, and receive PA decisions electronically in real time

A PARDD API enables providers to query payer systems in real time for PA requirements, submit required clinical documentation electronically, and receive PA decisions — streamlining the entire prior authorization workflow from within their own systems.

Which of the following is a primary challenge in implementing interoperable electronic prior authorization systems across health plans?

Answer: Lack of standardized data formats and widely varying payer-specific PA requirements across different health plans

A primary challenge in ePA interoperability is inconsistency in data standards and differing payer-specific PA requirements, which creates significant technical and administrative barriers for providers submitting requests across multiple health plans.

Under HIPAA's Breach Notification Rule, what must a covered entity do when a PA information system experiences a breach of unsecured protected health information?

Answer: Notify affected individuals, the HHS Secretary, and in some cases the media, within timeframes specified by the Breach Notification Rule

Under the HIPAA Breach Notification Rule, covered entities must notify affected individuals (within 60 days of discovery), the HHS Secretary, and for breaches affecting 500 or more individuals in a state or jurisdiction, prominent local media outlets.