PACS Documentation & Record Management 3 — Questions and Answers
Question 1: A payer requests additional clinical documentation during the prior authorization review process. This request is commonly called a(n):
- Concurrent review notice
- Additional Development Request (ADR) (Correct answer)
- Remittance advice
- Coordination of benefits inquiry
Correct answer: Additional Development Request (ADR)
An Additional Development Request (ADR) is a formal payer request for supplementary clinical or administrative documentation to complete the review.
Question 2: Which data element in an electronic prior authorization (ePA) transaction most commonly maps to ASC X12 278 segment NM1?
- Service type code
- Subscriber or patient name (Correct answer)
- Diagnosis code
- Place of service code
Correct answer: Subscriber or patient name
The NM1 loop in the X12 278 transaction carries name information for the subscriber, patient, provider, or other entities.
Question 3: For Medicare Advantage plans, prior authorization documentation must typically be maintained by the provider for at least:
- 1 year after the date of service
- 5 years after the date of service
- 10 years after the date of service (Correct answer)
- Indefinitely
Correct answer: 10 years after the date of service
CMS requires Medicare Advantage plan providers to retain records for 10 years to support potential audits and overpayment reviews.
Question 4: A PACS specialist must document a 'same or similar' equipment check before authorizing durable medical equipment (DME). This check verifies that:
- The equipment price is below Medicare's fee schedule
- The patient does not already have an active authorization for identical or comparable equipment (Correct answer)
- The equipment supplier is accredited by The Joint Commission
- The patient has met their annual deductible
Correct answer: The patient does not already have an active authorization for identical or comparable equipment
Medicare and most payers prohibit duplicate authorization for same or similar equipment to prevent duplicate billing.
Question 5: When a prior authorization is obtained for a procedure that later changes in scope, the PACS specialist should:
- Proceed with the original authorization since it is already approved
- Document the change and submit a new or amended authorization request (Correct answer)
- Cancel the insurance policy and re-enroll the patient
- Use a different provider's NPI to bill the revised procedure
Correct answer: Document the change and submit a new or amended authorization request
A material change in procedure type or scope voids the original authorization; a new request must document the clinical change.
Question 6: Which document type serves as the primary source of truth when auditing whether a prior authorization was required for a service?
- The provider's superbill
- The payer's benefit grid or coverage determination policy (Correct answer)
- The patient's explanation of benefits (EOB)
- The pharmacy drug formulary
Correct answer: The payer's benefit grid or coverage determination policy
The payer's coverage determination policy (benefit grid) defines which services require prior authorization and under what conditions.
Question 7: A prior authorization specialist encounters a fax containing PHI that was sent to the wrong number. Under HIPAA, the first required action is to:
- Destroy the fax and take no further action
- Document the misdirected fax and conduct a breach risk assessment (Correct answer)
- Post a public notice of the error
- Immediately notify the Office of Inspector General
Correct answer: Document the misdirected fax and conduct a breach risk assessment
HIPAA's Breach Notification Rule requires a four-factor risk assessment to determine whether notification obligations are triggered.
PACS Documentation & Record Management 3
A payer requests additional clinical documentation during the prior authorization review process.
This request is commonly called a(n):