PACS Compliance Regulations & Ethical Standards 2 — Questions and Answers
Question 1: Under HIPAA, which standard governs the electronic transmission of prior authorization requests between providers and health plans?
- ASC X12 278 Transaction Set (Correct answer)
- ASC X12 837 Transaction Set
- NCPDP SCRIPT Standard
- HL7 FHIR R4
Correct answer: ASC X12 278 Transaction Set
The ASC X12 278 Health Care Services Review transaction set is the HIPAA-mandated standard for electronic prior authorization requests and responses.
Question 2: A prior authorization specialist receives a request that appears to have been submitted by an unauthorized staff member using another employee's credentials. The BEST first action is to:
- Process the request since the clinical information looks valid
- Immediately report the potential security breach to the privacy officer (Correct answer)
- Contact the patient to verify the request details
- Deny the request and document the reason
Correct answer: Immediately report the potential security breach to the privacy officer
Unauthorized credential use is a potential HIPAA security violation requiring immediate escalation to the privacy/security officer.
Question 3: Which federal law established the requirement for health plans to provide a Summary of Benefits and Coverage (SBC) that includes information about prior authorization requirements?
- ERISA
- COBRA
- The Affordable Care Act (ACA) (Correct answer)
- HIPAA Privacy Rule
Correct answer: The Affordable Care Act (ACA)
The Affordable Care Act mandated that health plans provide an SBC document, which must disclose coverage limitations including prior authorization requirements.
Question 4: When a prior authorization is denied, the Utilization Review Accreditation Commission (URAC) requires that the denial notice include all of the following EXCEPT:
- The clinical rationale for the denial
- The name of the treating physician (Correct answer)
- Information about the appeals process
- The specific criteria used in the decision
Correct answer: The name of the treating physician
URAC standards require denial notices to include clinical rationale, criteria used, and appeals information, but do not require disclosure of the treating physician's name.
Question 5: Under the Mental Health Parity and Addiction Equity Act (MHPAEA), which scenario represents a potential parity violation?
- Requiring prior authorization for inpatient psychiatric stays but not medical stays (Correct answer)
- Applying the same deductible to mental health and medical services
- Covering both mental health and medical services under the same network
- Using evidence-based criteria for both mental health and medical reviews
Correct answer: Requiring prior authorization for inpatient psychiatric stays but not medical stays
MHPAEA prohibits applying more restrictive prior authorization requirements to mental health/substance use disorder benefits than to comparable medical/surgical benefits.
Question 6: A pharmacist calls requesting prior authorization status for a patient and provides the patient's name and date of birth. The specialist should:
- Provide the full authorization status since pharmacists are healthcare providers
- Verify the pharmacist's identity and confirm they have a treatment relationship before disclosing (Correct answer)
- Require a written authorization from the patient before providing any information
- Transfer the call to the medical director
Correct answer: Verify the pharmacist's identity and confirm they have a treatment relationship before disclosing
HIPAA permits disclosure to treatment providers with a need-to-know, but the specialist must verify the caller's identity and treatment relationship before releasing PHI.
Question 7: The False Claims Act's 'qui tam' provision allows:
- Health plans to sue providers who submit fraudulent claims
- Private citizens to file lawsuits on behalf of the government and share in any recovery (Correct answer)
- Government agencies to impose administrative penalties without court involvement
- Medicare to conduct prepayment audits on high-risk providers
Correct answer: Private citizens to file lawsuits on behalf of the government and share in any recovery
The qui tam provision empowers whistleblowers (relators) to file False Claims Act suits on the government's behalf and receive a portion of any recovered funds.
PACS Compliance Regulations & Ethical Standards 2
Under HIPAA, which standard governs the electronic transmission of prior authorization requests between providers and health plans?