PACS Regulatory Framework & Requirements 3

Question 1

A Medicaid managed care organization denies a prior authorization request. Under 42 CFR Part 438, within how many calendar days must the enrollee receive written notice of the denial?

Accepted Answer

14 calendar days

Answer

Under 42 CFR Part 438.404, Medicaid managed care organizations must provide written notice of an adverse action, including a PA denial, within 14 calendar days.

Question 2

Which provision of the Affordable Care Act requires non-grandfathered health plans to cover certain preventive services without prior authorization or cost-sharing?

Accepted Answer

Section 2713

Answer

ACA Section 2713 requires non-grandfathered health plans to cover USPSTF A/B-rated preventive services without cost-sharing or prior authorization requirements.

Question 3

When a Medicare Advantage plan denies a prior authorization as not medically necessary, the denial notice must inform beneficiaries of their right to request a(n):

Accepted Answer

Organization Determination and subsequent appeals

Answer

MA plan PA denials constitute organization determinations, and enrollees must be notified of their right to appeal through reconsideration, ALJ, MAC, and judicial review.

Question 4

Under HIPAA's Administrative Simplification provisions, what is the standard electronic transaction code set used for prior authorization requests?

Accepted Answer

ASC X12 278

Answer

The ASC X12 278 Health Care Services Review transaction is the HIPAA-mandated standard for electronic prior authorization requests and responses.

Question 5

A health plan uses clinical criteria developed by a nationally recognized organization to make PA decisions. This practice is most closely aligned with which regulatory requirement?

Accepted Answer

Using evidence-based criteria per URAC and NCQA standards

Answer

URAC and NCQA accreditation standards require health plans to use evidence-based, nationally recognized clinical criteria (such as MCG or InterQual) for utilization management decisions.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Regulatory Framework & Requirements 3