PACS Prior Authorization Processes & Documentation 2

Question 1

Which document is typically required by payers when submitting a prior authorization request for a specialty medication?

Accepted Answer

Letter of Medical Necessity

Answer

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?

Accepted Answer

To allow coverage of a non-formulary drug when formulary alternatives are contraindicated or ineffective

Answer

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?

Accepted Answer

72 hours for standard decisions

Answer

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?

Accepted Answer

An exemption from prior authorization for providers with high approval rates

Answer

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?

Accepted Answer

Evidence of trial and failure of required first-line therapies

Answer

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.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Prior Authorization Processes & Documentation 2