PACS Compliance Regulations & Ethical Standards 2

Question 1

Under HIPAA, which standard governs the electronic transmission of prior authorization requests between providers and health plans?

Accepted Answer

ASC X12 278 Transaction Set

Answer

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:

Accepted Answer

Immediately report the potential security breach to the privacy officer

Answer

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?

Accepted Answer

The Affordable Care Act (ACA)

Answer

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:

Accepted Answer

The name of the treating physician

Answer

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?

Accepted Answer

Requiring prior authorization for inpatient psychiatric stays but not medical stays

Answer

MHPAEA prohibits applying more restrictive prior authorization requirements to mental health/substance use disorder benefits than to comparable medical/surgical benefits.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Compliance Regulations & Ethical Standards 2