Technology & Information Systems in Prior Authorization Flashcards

Which ASC X12 transaction set is the HIPAA-mandated standard for submitting prior authorization requests and referrals?

Answer: ASC X12 278

The ASC X12 278 Health Care Services Review transaction is the HIPAA-mandated electronic standard for submitting prior authorization requests and referrals between providers and payers.

What is the primary purpose of an Electronic Prior Authorization (ePA) system?

Answer: To automate and streamline the PA submission and approval workflow

ePA systems are designed to automate and streamline the prior authorization submission, tracking, and approval process, reducing administrative burden and turnaround time compared to manual methods.

Which organization develops and maintains the NCPDP SCRIPT standard used for electronic pharmacy prior authorization?

Answer: National Council for Prescription Drug Programs (NCPDP)

The National Council for Prescription Drug Programs (NCPDP) develops and maintains the SCRIPT standard, which is widely used for electronic pharmacy transactions including prior authorization messaging.

What does 'real-time prior authorization' mean in the context of electronic PA systems?

Answer: Immediate automated approval or denial decisions generated at the point of care

Real-time prior authorization refers to immediate, automated approval or denial decisions generated at the point of prescribing or ordering care, eliminating the delays associated with manual review.

Under the 21st Century Cures Act, CMS was directed to implement electronic prior authorization for which Medicare program?

Answer: Medicare Part D (prescription drug plans)

The 21st Century Cures Act directed CMS to implement electronic prior authorization for Medicare Part D prescription drug plans to improve efficiency and reduce administrative burden for pharmacy PA.

What is the key benefit of integrating prior authorization systems with Electronic Health Records (EHR)?

Answer: It enables automatic population of clinical data into PA requests, reducing manual data entry

EHR integration allows clinical data already documented by the provider to automatically populate PA request forms, reducing manual data entry, minimizing errors, and accelerating the authorization process.

Which federal rule, finalized in 2024, requires impacted payers to implement HL7 FHIR-based APIs to streamline prior authorization processes?

Answer: CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F)

The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), finalized in January 2024, requires impacted payers to implement FHIR-based APIs to automate and improve transparency in prior authorization workflows.