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

HL7 FHIR (Fast Healthcare Interoperability Resources) is a data exchange standard that enables structured, real-time sharing of healthcare information, including prior authorization data, between payers and providers.

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

Gold carding (also called provider exemption programs) exempts providers with consistently high PA approval rates from submitting PA requests for specific services, reducing administrative burden while preserving oversight.

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

PA attachments are electronic clinical documents — such as medical records, lab results, or clinical notes — submitted alongside a PA request to provide evidence supporting medical necessity.

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

The NCPDP SCRIPT standard provides a standardized electronic message format that enables prescribers and payers to exchange pharmacy prior authorization requests, clinical information, and responses efficiently.

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

The HIPAA Security Rule (45 CFR Part 164) requires covered entities and business associates to implement administrative, physical, and technical safeguards to protect electronic PHI processed or stored in PA systems.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Technology & Information Systems in Prior Authorization 2