PACS Compliance Regulations & Ethical Standards 4

Question 1

A prior authorization specialist receives a request for an experimental treatment that is not covered under the plan. The specialist should:

Accepted Answer

Deny the request and notify the member of the denial and their appeal rights

Answer

Non-covered services must be denied with proper notification, including the specific reason and the member's right to appeal the decision.

Question 2

The 21st Century Cures Act requires health plans to implement electronic prior authorization APIs based on which standard by 2027?

Accepted Answer

HL7 FHIR

Answer

The 21st Century Cures Act mandates FHIR-based APIs to enable real-time electronic prior authorization, reducing administrative burden.

Question 3

Which of the following situations would constitute 'steering' in violation of ethical standards for prior authorization?

Accepted Answer

Approving only requests for services from a specific provider the plan has a financial interest in

Answer

Steering patients toward providers based on the plan's financial interest rather than clinical criteria is an ethical violation that can also violate anti-kickback laws.

Question 4

Under ERISA, when a health plan denies a prior authorization claim, the member has the right to a full and fair review. This means the review must be conducted by someone who is:

Accepted Answer

Independent of the initial determination and not a subordinate of the initial reviewer

Answer

ERISA requires that appeals be reviewed by someone independent of the initial reviewer to ensure impartiality and a genuine second review.

Question 5

A member's authorized representative submits a prior authorization request. To be valid, the representative must provide:

Accepted Answer

Written documentation of their authority, such as a power of attorney or signed authorization

Answer

Written documentation of representative authority is required to protect the member's rights and ensure PHI is only disclosed to authorized parties.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Compliance Regulations & Ethical Standards 4