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Prior Authorization & Precertification Flashcards

7 cards from real CPAT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.

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  1. Which payer program uses a list of services that require authorization, often published in a payer's provider manual?

    Answer: Prior authorization list (PAL)

    Payers publish a prior authorization list identifying exactly which services, drugs, or procedures require advance approval before coverage applies.

  2. A precertification is obtained for 5 inpatient days. The patient stays 8 days. What must the patient account technician do?

    Answer: Request a concurrent review extension for the additional days

    A concurrent review extension must be requested when the patient's stay exceeds the originally authorized length to maintain coverage for additional days.

  3. Which coding set is most commonly used to communicate procedures when requesting prior authorization?

    Answer: CPT/HCPCS codes

    CPT and HCPCS codes identify the specific procedures requested, which payers use to evaluate authorization criteria.

  4. What is the primary purpose of a Letter of Medical Necessity (LMN) in the authorization process?

    Answer: To demonstrate that a requested service is clinically appropriate for the patient's condition

    An LMN is written by the physician to justify that the requested service is medically necessary, supporting the authorization request.

  5. Under Medicare Advantage plans, which entity is responsible for issuing prior authorizations?

    Answer: The Medicare Advantage plan (private insurer)

    Medicare Advantage plans are administered by private insurers who set their own coverage policies, including prior authorization requirements, within CMS guidelines.

  6. A referral authorization differs from a prior authorization in that it:

    Answer: Is issued by the primary care physician to allow the patient to see a specialist

    A referral authorization is a PCP's formal approval for a patient to see a specialist, which is distinct from a payer's prior authorization for a specific service.

  7. If a prior authorization is obtained but the patient's insurance coverage lapses before the service is rendered, the authorization is:

    Answer: Voided, as authorization is contingent on active coverage at the time of service

    A prior authorization is only valid while the patient has active coverage with that payer; a lapse in coverage invalidates the authorization.