PACS Technology & Information Systems in Prior Authorization 3

Question 1

What is the purpose of the HL7 Da Vinci Prior Authorization Support (PAS) FHIR Implementation Guide?

Accepted Answer

To define FHIR-based workflows enabling providers to submit and manage PA requests directly from their EHR to payer systems

Answer

To standardize the clinical criteria payers use when making PA coverage decisions

Answer

To establish reimbursement rates for prior authorization administrative processing services

Answer

To create a national registry of all PA approvals and denials for research purposes

Question 2

Step therapy requirements managed through PA systems require providers to document what before a higher-cost treatment can be authorized?

Accepted Answer

That the patient tried and failed clinically appropriate lower-cost or preferred treatments before the alternative is authorized

Answer

Pre-approval from a specialist and three prior PA submissions

Answer

Completion of multiple prior authorization forms for each treatment tier reviewed simultaneously

Answer

Escalation of the PA request through two levels of clinical review by the payer's medical director

Question 3

What is the primary role of audit logging in prior authorization information systems?

Accepted Answer

To create a traceable, time-stamped record of all PA transactions for compliance, fraud detection, and accountability

Answer

To automatically approve all PA requests that successfully complete the audit trail process

Answer

To log provider login attempts exclusively for cybersecurity and access control purposes

Answer

To generate billing reports for administrative services fees associated with PA processing

Question 4

Under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), what are the required PA decision timeframes for impacted payers?

Accepted Answer

72 hours for urgent (expedited) requests and 7 calendar days for standard requests

Answer

24 hours for urgent requests and 3 business days for standard requests

Answer

48 hours for all requests regardless of urgency classification

Answer

1 business day for urgent requests and 14 calendar days for standard requests

Question 5

What is the purpose of a Prior Authorization Requirements, Documentation, and Decision (PARDD) API in PA technology systems?

Accepted Answer

To enable providers to query a payer's PA requirements, submit clinical documentation, and receive PA decisions electronically in real time

Answer

To allow patients to independently submit and track their own PA requests through a consumer-facing portal

Answer

To archive historical PA decisions and create longitudinal data sets for quality improvement research

Answer

To manage provider network credentialing verification and contract compliance monitoring

Question 6

Which of the following is a primary challenge in implementing interoperable electronic prior authorization systems across health plans?

Accepted Answer

Lack of standardized data formats and widely varying payer-specific PA requirements across different health plans

Answer

An excessive number of qualified clinical reviewers making staffing management difficult

Answer

An overabundance of ePA submission portals that create confusion due to their ease of use

Answer

PA electronic approval rates that are too high, reducing the clinical review oversight needed

Question 7

Under HIPAA's Breach Notification Rule, what must a covered entity do when a PA information system experiences a breach of unsecured protected health information?

Accepted Answer

Notify affected individuals, the HHS Secretary, and in some cases the media, within timeframes specified by the Breach Notification Rule

Answer

No notification is required if the breach was determined to be unintentional or accidental

Answer

Notify only the state insurance commissioner and the provider whose patient data was affected

Answer

Immediately delete all affected PA records to prevent further unauthorized access to the information