PACS Insurance Verification & Coverage Criteria 3

Question 1

A prior authorization is approved for 12 physical therapy visits. After visit 8, the therapist believes 8 additional visits are needed. What is the CORRECT action?

Accepted Answer

Submit a concurrent review or extension request before the authorized visits are exhausted

Answer

Concurrent review or an extension request must be submitted while authorized visits remain to avoid a gap in coverage or retrospective denial.

Question 2

Which of the following best describes the difference between a precertification and a predetermination in insurance verification?

Accepted Answer

Precertification is required before service and authorizes coverage; predetermination estimates patient cost-sharing but does not guarantee benefits

Answer

Precertification authorizes a service as medically necessary, while predetermination is a non-binding cost estimate that does not constitute a promise of payment.

Question 3

When verifying coverage for a patient with an Exclusive Provider Organization (EPO) plan, which statement is MOST accurate?

Accepted Answer

EPO members must use in-network providers or services will not be covered except in emergencies

Answer

EPO plans restrict coverage to in-network providers (no out-of-network coverage except emergencies) but generally do not require PCP referrals, unlike HMOs.

Question 4

A PACS specialist is reviewing coverage criteria for bariatric surgery. The plan requires a BMI of ≥40 or ≥35 with comorbidities and 6 months of supervised weight-loss program documentation. The patient's BMI is 36 with documented Type 2 diabetes. Which criterion applies?

Accepted Answer

The patient may qualify under the BMI ≥35 with comorbidity criterion if supervised weight-loss documentation is complete

Answer

A BMI of 36 with Type 2 diabetes meets the ≥35 with comorbidity threshold, but the 6-month supervised program documentation must also be submitted.

Question 5

Under the ACA, which category of services must most health plans cover without patient cost-sharing (no copay, deductible, or coinsurance)?

Accepted Answer

Preventive services rated A or B by the U.S. Preventive Services Task Force (USPSTF)

Answer

The ACA mandates that non-grandfathered plans cover USPSTF A/B-rated preventive services without any patient cost-sharing.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Insurance Verification & Coverage Criteria 3