PACS Compliance Regulations & Ethical Standards 3

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?

Accepted Answer

7 calendar days

Answer

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?

Accepted Answer

Beneficence

Answer

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:

Accepted Answer

Document the concern and report it to the compliance department

Answer

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:

Accepted Answer

Based on sound clinical evidence and reviewed periodically

Answer

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:

Accepted Answer

Modified approval

Answer

A modified approval occurs when the health plan authorizes a different service or level of care than what was originally requested.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Compliance Regulations & Ethical Standards 3