CMAA Prior Authorizations and Referral Management — Questions and Answers
Question 1: A physician orders an MRI for a patient. Before scheduling the exam, the medical administrative assistant contacts the insurance company for approval. This process is called:
- Submitting a superbill
- Obtaining prior authorization (Correct answer)
- Filing a coordination of benefits form
- Requesting an Explanation of Benefits (EOB)
Correct answer: Obtaining prior authorization
Prior authorization (pre-auth or pre-approval) is the payer's requirement to approve certain services before they are rendered, confirming medical necessity and coverage. A superbill is a billing document, coordination of benefits applies when a patient has two insurers, and an EOB is a statement sent after a claim is processed.
Question 2: When a prior authorization request is denied by the payer, what is the MOST appropriate next step for the medical administrative assistant?
- Reschedule the patient for a different, less expensive procedure
- Have the patient sign a financial waiver and proceed with the service
- Notify the treating provider and initiate the payer's formal appeal process (Correct answer)
- Bill the patient directly without informing the provider of the denial
Correct answer: Notify the treating provider and initiate the payer's formal appeal process
A denial is not always final. The correct step is to inform the provider, who can supply additional clinical documentation supporting medical necessity as part of a formal payer appeal. Proceeding without authorization or billing the patient without disclosure exposes the practice to legal and financial risk.
Question 3: Which of the following information is typically required when submitting a prior authorization request to an insurance company?
- Patient's credit score and billing payment history
- Provider's NPI, procedure codes (CPT), diagnosis codes (ICD), and clinical justification (Correct answer)
- The facility's Joint Commission accreditation certificate number
- Patient's previous year's tax return and income verification
Correct answer: Provider's NPI, procedure codes (CPT), diagnosis codes (ICD), and clinical justification
Payers evaluate prior authorization requests using clinical and administrative data: the ordering provider's NPI (National Provider Identifier), CPT codes for the requested service, ICD-10 diagnosis codes, and documentation justifying medical necessity. Financial or accreditation information is not part of this process.
Question 4: A primary care physician directs a patient to see a cardiologist. The medical administrative assistant's responsibility in this workflow is to:
- Contact the cardiologist directly and schedule the patient without any documentation
- Generate and transmit the referral order to the specialist's office and verify it was received (Correct answer)
- Allow the patient to self-refer and contact the specialist on their own
- Complete the specialist's intake forms on behalf of the patient
Correct answer: Generate and transmit the referral order to the specialist's office and verify it was received
The administrative assistant is responsible for processing the referral order — sending the physician-generated referral to the specialist, confirming receipt, and often verifying that the referral is authorized by the patient's insurance plan before the appointment occurs.
Question 5: A prior authorization was approved on March 1 with a 90-day validity window. The patient's procedure has not yet been scheduled. What must the administrative assistant do?
- Nothing — once approved, a prior authorization never expires
- Ensure the procedure is scheduled and performed before May 30, or obtain re-authorization (Correct answer)
- Resubmit the authorization request every 30 days regardless of the expiration date
- Cancel the authorization and bill the patient directly for the service
Correct answer: Ensure the procedure is scheduled and performed before May 30, or obtain re-authorization
Prior authorizations are valid for a defined period (commonly 60–90 days, depending on the payer). Services must be rendered within that window. If the authorization expires before the service is performed, the practice must request re-authorization to ensure coverage.
Question 6: Which insurance plan type most commonly requires patients to obtain a referral from their PCP before seeing an out-of-network specialist?
- Preferred Provider Organization (PPO)
- High-Deductible Health Plan (HDHP)
- Health Maintenance Organization (HMO) (Correct answer)
- Fee-for-Service indemnity plan
Correct answer: Health Maintenance Organization (HMO)
HMO plans use a gatekeeper model in which the PCP must issue a referral for specialist care. Out-of-network specialist visits are generally not covered at all under an HMO without a referral. PPOs and indemnity plans allow direct specialist access without referrals.
CMAA Prior Authorizations and Referral Management
A physician orders an MRI for a patient.
Before scheduling the exam, the medical administrative assistant contacts the insurance company for approval.
This process is called: