PACS Technology & Information Systems in Prior Authorization 2

Question 1

What does HL7 FHIR stand for, and why is it significant in prior authorization?

Accepted Answer

Health Level 7 Fast Healthcare Interoperability Resources; enables structured real-time data exchange for PA between systems

Answer

Health Level 7 Fixed Interoperability Resource; standardizes PA form layouts across all payers

Answer

Health Link 7 Flexible Health Information Repository; stores PA records in a centralized database

Answer

Health Level 7 Federal Health Insurance Requirement; mandates PA for all federal health plans

Question 2

What is 'gold carding' in the context of prior authorization programs?

Accepted Answer

Exempting high-performing providers from PA requirements based on their consistently high approval history

Answer

Using a gold-standard clinical criteria set for evaluating all PA requests

Answer

A premium tier of expedited PA services available for high-cost procedures

Answer

Issuing a physical card to pre-approved providers allowing them to bypass the payer portal

Question 3

What is the purpose of a 'PA attachment' in electronic prior authorization transactions?

Accepted Answer

Clinical documentation submitted electronically alongside the PA request to support medical necessity

Answer

A physical document attached to the PA form and mailed to the payer

Answer

A financial guarantee attached to the PA request for billing assurance purposes

Answer

An addendum to the provider contract specifying PA requirements by service type

Question 4

Which of the following best describes the NCPDP SCRIPT standard's role in pharmacy prior authorization?

Accepted Answer

It provides a standardized electronic message format for pharmacy PA requests and responses between prescribers and payers

Answer

It establishes pricing standards and reimbursement rates for prescription drugs

Answer

It governs how retail pharmacies store and retain prescription dispensing records

Answer

It establishes clinical criteria and formulary tier placement for covered medications

Question 5

What HIPAA rule applies to electronic prior authorization systems that create, maintain, or transmit protected health information (PHI)?

Accepted Answer

HIPAA Security Rule, requiring administrative, physical, and technical safeguards specifically for electronic PHI (ePHI)

Answer

HIPAA Privacy Rule only, which governs all PHI regardless of format

Answer

HIPAA Breach Notification Rule only, which applies after a security incident occurs

Answer

HIPAA Enforcement Rule only, which establishes penalties for non-compliance

Question 6

What is 'auto-authorization' (auto-auth) in the context of prior authorization technology systems?

Accepted Answer

Automatic approval of PA requests that meet predefined clinical criteria without requiring manual clinical review

Answer

An authorization system that automatically approves all requests regardless of clinical criteria

Answer

An authorization that automatically renews each year without requiring resubmission by the provider

Answer

Software that automatically denies PA requests flagged as incomplete or missing required fields

Question 7

Which metric is most commonly used to measure the effectiveness of electronic prior authorization technology adoption?

Accepted Answer

ePA adoption rate — the percentage of total PA requests submitted electronically versus manually or by phone/fax

Answer

Provider satisfaction score with payer customer service representatives

Answer

Total number of PA requests submitted across all modalities in a calendar year

Answer

Average cost per PA request regardless of the submission method used