PACS Policy Development & Implementation 2

Question 1

When updating a prior authorization policy, which stakeholder group should be consulted FIRST to ensure clinical accuracy?

Accepted Answer

Clinical/medical staff

Answer

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?

Accepted Answer

The health plan or payer

Answer

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?

Accepted Answer

Evidence-based clinical guidelines

Answer

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?

Accepted Answer

60 days

Answer

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?

Accepted Answer

Exempting high-performing providers from routine PA requirements

Answer

Gold carding allows providers with high approval rates to bypass standard PA requirements, reducing administrative burden.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Policy Development & Implementation 2