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.
Read the first 7 Prior Authorization & Precertification flashcards as text
Which term describes the retrospective review by a payer of services already rendered to determine if they were medically necessary?
Answer: Post-service (retrospective) review
A retrospective review occurs after services are provided, when the payer evaluates whether those services met medical necessity criteria for coverage.
When a provider fails to obtain required prior authorization and the payer denies the claim, who typically bears financial responsibility?
Answer: The provider, for failing to follow payer requirements
When a provider neglects to obtain a required authorization, the payer may deny the claim and the provider—not the patient—is generally responsible for the resulting write-off.
Which of the following best describes an 'expedited' prior authorization request?
Answer: An urgent request required when a delay could seriously jeopardize the patient's health
An expedited authorization is required for urgent cases where the standard review timeline would harm the patient, and payers must respond faster than for routine requests.
HIPAA's Administrative Simplification provisions support prior authorization by:
Answer: Standardizing electronic transaction formats that can be used for authorization requests
HIPAA's administrative simplification rules establish standard electronic transaction sets (such as the 278 transaction) that streamline the submission of authorization requests.
The ASC X12 278 transaction set is used in healthcare to:
Answer: Transmit electronic prior authorization requests and responses
The X12 278 transaction is the HIPAA-standard electronic format specifically designed for health care services review (prior authorization) requests and responses.
A patient's prior authorization is approved for a specific CPT code, but the physician performs a slightly different procedure. What risk does this create?
Answer: A claim denial because the rendered service does not match the authorized service
Payers match claims to authorizations by CPT code; a mismatch between the authorized code and the billed code typically results in a denial.
Which action best supports compliance when tracking prior authorization expiration dates?
Answer: Maintaining a tickler system or authorization tracking log with expiration alerts
A proactive authorization tracking log with expiration alerts ensures services are rendered within authorized timeframes, preventing avoidable denials.