CHAA Pre-Authorization and Referrals Management 2

Question 1

What is the key difference between a pre-authorization and a referral?

Accepted Answer

Pre-authorization is insurance approval confirming medical necessity and coverage; a referral is a PCP order directing the patient to a specialist

Answer

Pre-authorization confirms insurance coverage while a referral directs a patient between providers.

Question 2

A pre-authorization request has been denied. What options are available?

Accepted Answer

File a peer-to-peer review, a formal appeal with additional documentation, or an expedited appeal for urgent situations

Answer

Pre-authorization denials can be challenged through multiple appeal mechanisms.

Question 3

What information is required when submitting a pre-authorization request?

Accepted Answer

Patient demographics, insurance information, diagnosis codes, procedure codes, clinical documentation, and provider information

Answer

Pre-authorization requires comprehensive patient, insurance, clinical, and provider information.

Question 4

A patient's PCP referral has expired. They're at the facility for their specialist appointment. What should patient access do?

Accepted Answer

Contact the PCP's office for a new referral, inform the patient, and coordinate with the specialist on timing

Answer

An expired referral requires proactive resolution while minimizing care disruption.

Question 5

What is retrospective authorization, and when is it used?

Accepted Answer

Authorization obtained after services are rendered, typically for emergencies or when prior authorization couldn't be obtained in time

Answer

Retrospective authorization is sought after services are provided in emergencies or urgent situations.

CHAA - Certified Healthcare Access Associate Practice Test