PACS Documentation & Record Management 4

Question 1

Which of the following best describes 'prior authorization creep' in a documentation context?

Accepted Answer

A payer expanding the list of services requiring prior authorization over time

Answer

Prior authorization creep refers to payers progressively adding more services and drugs to their prior authorization required lists, increasing the administrative burden.

Question 2

When documenting a phone-based prior authorization approval, which information must be captured to make the record legally defensible?

Accepted Answer

Approval reference number, date, time, agent name, and authorized service details

Answer

A verbal authorization is only defensible if the record captures the reference number, agent identity, timestamp, and specific service authorized.

Question 3

An authorization record is flagged for a coding mismatch: the ICD-10 code on the authorization differs from the code on the claim. The MOST likely outcome is:

Accepted Answer

Claim denial or delay pending reconciliation of the diagnosis codes

Answer

Payer systems match authorization and claim data; a diagnosis code discrepancy triggers a denial or pends the claim for manual review.

Question 4

Under the No Surprises Act, what documentation must providers give patients before rendering out-of-network services that may require prior authorization?

Accepted Answer

A Good Faith Estimate (GFE) of expected costs

Answer

The No Surprises Act requires a Good Faith Estimate for uninsured/self-pay patients and notice-and-consent forms for insured patients receiving out-of-network services.

Question 5

Which clinical document is most commonly used to establish medical necessity for a specialty drug prior authorization?

Accepted Answer

Step therapy failure documentation showing inadequate response to formulary alternatives

Answer

Payers require step therapy failure documentation to confirm that lower-cost alternatives were tried and failed before approving high-cost specialty drugs.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Documentation & Record Management 4