PACS Policy Development & Implementation 2 — Questions and Answers
Question 1: When updating a prior authorization policy, which stakeholder group should be consulted FIRST to ensure clinical accuracy?
- Billing department
- Clinical/medical staff (Correct answer)
- Legal counsel
- IT department
Correct answer: Clinical/medical staff
Clinical staff must validate that policy requirements align with evidence-based medical practice before other departments review.
Question 2: A prior authorization policy states that 'medically necessary' services are covered. Who is primarily responsible for defining 'medical necessity' within the policy?
- The treating physician
- The health plan or payer (Correct answer)
- State insurance regulators
- The patient's employer
Correct answer: The health plan or payer
The health plan or payer defines medical necessity criteria within their policies, though they must align with state and federal standards.
Question 3: Which document type serves as the foundation for developing a prior authorization policy?
- Provider contract
- Evidence-based clinical guidelines (Correct answer)
- Patient satisfaction surveys
- Claims adjudication reports
Correct answer: Evidence-based clinical guidelines
Evidence-based clinical guidelines (from bodies like MCSI or specialty societies) provide the clinical foundation for PA policy criteria.
Question 4: A PA policy is being implemented that requires authorization for a previously non-covered service. What is the minimum required notice period under most state regulations before this change takes effect?
- 15 days
- 30 days
- 60 days (Correct answer)
- 90 days
Correct answer: 60 days
Most state regulations require at least 60 days' advance notice to providers before implementing significant PA policy changes.
Question 5: Which of the following best describes a 'gold carding' policy in prior authorization?
- A premium insurance tier with reduced copays
- Exempting high-performing providers from routine PA requirements (Correct answer)
- A fast-track approval for gold-standard treatments
- An expedited review process for emergency services
Correct answer: Exempting high-performing providers from routine PA requirements
Gold carding allows providers with high approval rates to bypass standard PA requirements, reducing administrative burden.
Question 6: When implementing a new PA policy, which element MUST be included to comply with the Affordable Care Act's transparency requirements?
- Provider reimbursement rates
- The clinical criteria used to make coverage determinations (Correct answer)
- Internal reviewer credentials
- Proprietary algorithm details
Correct answer: The clinical criteria used to make coverage determinations
The ACA requires health plans to make the clinical criteria used for coverage determinations available to members and providers upon request.
Question 7: A utilization management committee is reviewing whether to add a new biologic medication to the PA required list. Which factor is MOST critical in this policy decision?
- The medication's brand name recognition
- Cost-effectiveness and comparative clinical evidence (Correct answer)
- The pharmaceutical manufacturer's market share
- The number of patient requests received
Correct answer: Cost-effectiveness and comparative clinical evidence
UM committees must weigh clinical evidence and cost-effectiveness to ensure PA requirements are medically justified and not solely cost-driven.
PACS Policy Development & Implementation 2
When updating a prior authorization policy, which stakeholder group should be consulted FIRST to ensure clinical accuracy?