PACS Compliance Regulations & Ethical Standards 3 — Questions and Answers
Question 1: Under the Consolidated Appropriations Act (CAA) of 2021, health plans are required to provide prior authorization decisions for non-urgent care within how many calendar days?
- 3 calendar days
- 7 calendar days (Correct answer)
- 14 calendar days
- 30 calendar days
Correct answer: 7 calendar days
While specific timelines vary by state and plan type, the CAA and CMS rules generally require non-urgent prior authorization decisions within 7 calendar days.
Question 2: Which ethical principle requires a prior authorization specialist to act in the patient's best interest, even when it conflicts with the health plan's financial interests?
- Autonomy
- Non-maleficence
- Beneficence (Correct answer)
- Justice
Correct answer: Beneficence
Beneficence is the ethical obligation to act in the patient's best interest and promote their well-being above other considerations.
Question 3: A prior authorization specialist notices that their supervisor is routinely approving requests without completing the required clinical review. The specialist's MOST appropriate action is to:
- Follow the supervisor's lead to maintain consistency
- Document the concern and report it to the compliance department (Correct answer)
- Confront the supervisor publicly to stop the practice
- Resign from the position to avoid liability
Correct answer: Document the concern and report it to the compliance department
Reporting compliance concerns to the appropriate internal department protects both patients and the organization while using proper escalation channels.
Question 4: The NCQA standards for utilization management require that clinical criteria used for prior authorization decisions be:
- Developed internally by each health plan's medical staff
- Based on sound clinical evidence and reviewed periodically (Correct answer)
- Approved by state insurance commissioners before use
- Updated annually regardless of changes in clinical evidence
Correct answer: Based on sound clinical evidence and reviewed periodically
NCQA requires that UM criteria be based on sound clinical evidence and reviewed and updated as new evidence emerges.
Question 5: When a prior authorization is approved, but for a different service than requested, this is known as a:
- Partial denial
- Modified approval (Correct answer)
- Conditional certification
- Administrative redirect
Correct answer: Modified approval
A modified approval occurs when the health plan authorizes a different service or level of care than what was originally requested.
Question 6: Under ADA Section 504 and the Rehab Act, health plans must ensure their prior authorization processes are accessible to members who are:
- Over age 65 only
- Disabled and require communication accommodations (Correct answer)
- Native language speakers only
- Rural residents with limited internet access
Correct answer: Disabled and require communication accommodations
Plans must provide reasonable accommodations, such as accessible formats and interpreter services, to ensure disabled members can access the prior authorization process.
Question 7: Which document outlines a health plan's commitment to fair and impartial utilization review, including prior authorization, and is required by most accrediting bodies?
- Certificate of Coverage
- Utilization Management Program Description (Correct answer)
- Explanation of Benefits
- Member Rights and Responsibilities Statement
Correct answer: Utilization Management Program Description
The Utilization Management Program Description details the plan's UM policies, criteria, and processes, and is a standard accreditation requirement.
PACS Compliance Regulations & Ethical Standards 3
Under the Consolidated Appropriations Act (CAA) of 2021, health plans are required to provide prior authorization decisions for non-urgent care within how many calendar days?