PACS Prior Authorization Processes & Documentation 2 — Questions and Answers
Question 1: Which document is typically required by payers when submitting a prior authorization request for a specialty medication?
- Patient's driver's license
- Letter of Medical Necessity (Correct answer)
- Insurance card front and back copy
- Pharmacy benefit card
Correct answer: Letter of Medical Necessity
A Letter of Medical Necessity written by the prescribing clinician is a standard payer requirement for specialty medication prior authorization requests.
Question 2: What is the primary purpose of a formulary exception in the prior authorization process?
- To expedite standard prior authorization reviews
- To allow coverage of a non-formulary drug when formulary alternatives are contraindicated or ineffective (Correct answer)
- To waive copay requirements for preferred medications
- To extend an existing authorization beyond its original end date
Correct answer: To allow coverage of a non-formulary drug when formulary alternatives are contraindicated or ineffective
A formulary exception allows a patient to receive coverage for a drug not on the payer's formulary when covered alternatives have failed or are clinically inappropriate.
Question 3: When a prior authorization is denied, which regulatory timeframe must Medicare Advantage plans meet for providing a written denial notice?
- 24 hours
- 48 hours
- 3 calendar days
- 72 hours for standard decisions (Correct answer)
Correct answer: 72 hours for standard decisions
Medicare Advantage plans must issue written denial notices within 72 hours for standard prior authorization decisions.
Question 4: Which of the following best describes a 'gold carding' program in prior authorization?
- A premium tier authorization requiring extra documentation
- An exemption from prior authorization for providers with high approval rates (Correct answer)
- A fast-track program for high-cost medications only
- A process for retrospective authorization of emergency services
Correct answer: An exemption from prior authorization for providers with high approval rates
Gold carding exempts providers with consistently high PA approval rates from needing to submit prior authorization requests for specific services.
Question 5: What clinical information is most critical when documenting step therapy requirements in a prior authorization request?
- Patient's primary care physician contact information
- Evidence of trial and failure of required first-line therapies (Correct answer)
- Patient's preferred pharmacy location
- Diagnosis code for the patient's secondary condition
Correct answer: Evidence of trial and failure of required first-line therapies
Documenting evidence of trial and failure of required first-line therapies is essential to satisfy step therapy requirements before a payer will authorize a preferred alternative.
Question 6: A provider submits a prior authorization for an MRI without contrast. The payer approves an MRI with contrast instead. What should the authorization specialist do?
- Proceed with the authorized service since it is an upgrade
- Contact the payer to clarify and correct the authorization to match the ordered service (Correct answer)
- Notify the patient and reschedule without further action
- Submit a new authorization for the original service without notifying anyone
Correct answer: Contact the payer to clarify and correct the authorization to match the ordered service
Authorization specialists must ensure the authorized service exactly matches the ordered service; a discrepancy requires payer clarification to avoid claim denial.
Question 7: Under HIPAA, which minimum necessary standard applies when requesting clinical documentation for prior authorization?
- All available patient records must be submitted to ensure completeness
- Only the information reasonably necessary to fulfill the authorization purpose should be requested (Correct answer)
- Providers must submit the full medical chart for every PA request
- Clinical notes from the past five years are always required
Correct answer: Only the information reasonably necessary to fulfill the authorization purpose should be requested
HIPAA's minimum necessary standard requires that only the information reasonably needed to process the prior authorization request be disclosed or requested.
PACS Prior Authorization Processes & Documentation 2
Which document is typically required by payers when submitting a prior authorization request for a specialty medication?