PACS Policy Development & Implementation 3

Question 1

Under NCQA accreditation standards, how often must a health plan conduct a formal review of its prior authorization policies?

Accepted Answer

Annually

Answer

NCQA requires health plans to review and update their UM/PA policies at least annually to ensure they reflect current clinical evidence.

Question 2

Which federal law specifically prohibits prior authorization requirements that create unreasonable barriers for mental health and substance use disorder benefits compared to medical/surgical benefits?

Accepted Answer

The Mental Health Parity and Addiction Equity Act (MHPAEA)

Answer

MHPAEA requires that PA requirements for mental health/SUD services be no more restrictive than those applied to comparable medical/surgical benefits.

Question 3

A PA policy needs to address step therapy (fail-first) requirements. Which statement best represents a compliant step therapy policy?

Accepted Answer

Step therapy requirements must have clinically supported exceptions and override procedures

Answer

Compliant step therapy policies must include clear, clinically justified criteria and documented exception/override pathways for appropriate cases.

Question 4

When drafting a PA policy for a high-volume procedure, which format is considered best practice for communicating criteria to providers?

Accepted Answer

Structured clinical decision trees or flowcharts

Answer

Structured decision trees or flowcharts help providers quickly identify whether authorization is required and what documentation is needed.

Question 5

A state legislature passes a law prohibiting PA for certain cancer screenings. How should a health plan's PA policy team respond?

Accepted Answer

Immediately update the PA list to remove those screenings within the required timeline

Answer

Health plans must comply with state mandates within required timeframes and update PA policies accordingly to remove newly prohibited requirements.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Policy Development & Implementation 3