PACS Documentation & Record Management 3

Question 1

A payer requests additional clinical documentation during the prior authorization review process. This request is commonly called a(n):

Accepted Answer

Additional Development Request (ADR)

Answer

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?

Accepted Answer

Subscriber or patient name

Answer

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:

Accepted Answer

10 years after the date of service

Answer

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:

Accepted Answer

The patient does not already have an active authorization for identical or comparable equipment

Answer

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:

Accepted Answer

Document the change and submit a new or amended authorization request

Answer

A material change in procedure type or scope voids the original authorization; a new request must document the clinical change.

(PACS) Prior Authorization Certified Specialist Practice Test