PRIOR AUTHORIZATION CERTIFIED SPECIALIST
PROGRAM EXAM QUESTIONS
Advanced Benefits Determination - answer- Term used by the Federal Employee
Anthem Plan. A method for receiving written approval of a proposed treatment.
Authorization - answer- A detailed presentation process from the healthcare provider to
the insurance or designated review company that requires affirmation of the clinical care
plan.
Authorization Procedure - answer- The steps outlined by an individual policy to obtain
treatment approval.
Case Management Approval - answer- A self-funded insurance policy that employs a
third party to review the intended treatment. The case manager involved is typically a
nurse. This is similar to an authorization in its process and purpose but is given a
different name by the insurance company.
Case Management Treatment Notification - answer- It is required by some insurers who
use third-party oversight but is not an authorization. Medical records are given to case
management and the insurance company notifies the self-insured employer what to
expect financially. Although pricing is not typically an insurance company's
responsibility, a case manager may ask for an estimate of the cost.
Chiropractor - answer- Practices medicine relating to diagnosis and treatment of
mechanical disorders of the musculoskeletal system, specifically the spine.
Commercial Policy - answer- An insurance policy other than Medicare that may be
purchased as an independent policy or by an employee of a corporation. This type of
insurance can be bought by employees with their paychecks at work. It is rare for a self-
employed person to buy an individual policy. It is not the same as a Marketplace plan.
Consolidated Omnibus Budget Reconciliation Act (COBRA) - answer- A federal law that
allows a person and any of their immediate family members to stay on an employer-
sponsored health plan under particular circumstances
DEA Registration Number - answer- An identifier assigned to a healthcare provider (ex.
physician, optometrist, dentist, veterinarian) by the United States Drug Enforcement
Administration that allows the provider to prescribe controlled substances.
Health Insurance Marketplace - answer- Also known as Marketplace Insurance. It is a
service that helps people shop for and enroll in affordable health insurance. The federal
government operates the Marketplace and is accessible for most states via
HealthCare.gov. However, coverage through Medicaid and the Children's Health
Insurance Program (CHIP) is done by each state. The Marketplace plan follows
,guidelines of the insurance company that sold the plan. Care must be taken with
healthcare providers in-network and is it vital to monitor for changes within the plan.
Insurance Benefits - answer- The financial properties of an insurance policy. For
instance, what the policy covers and at what percentages during an enrollment period.
Why is it important to get a reference number and send a follow up letter after telephone
prior authorization? - answer- Verbal authorizations may be difficult to prove and could
be reversed
TRUE/FALSE Medicare Advantage Plans will sometimes cover routine dental services.
- answer- True
Which professional is responsible for gathering information from a patient's medical
records and submitting an authorization request to the patient's insurer? - answer-
Provider's office staff
Under the prior authorization system, who decides whether a prescribed service,
medication, procedure, or device will be paid for? - answer- Payer or Insurance
company
On average, how much time each week do physicians spend on PA related activities? -
answer- Approximately 2 days
Which healthcare provider is responsible for diagnosing the patient and prescribing a
medication that may need a PA? - answer- Submitting Provider (Clinical Staff)
A medical office just learned that a prior authorization request for a patient was rejected.
Additional information about patient needs was submitted to the insurance company,
along with an appeal. Which intake or payer-side professional will review this first level
appeal? - answer- Medical Director
Which statement about prior authorizations is true? - answer- Most payers have
different departments that process medication and service line PAs.
What is a negative impact that the Prior Authorization (PA) system has on patients? -
answer- Increased processing time can lead to abandoned therapies.
Which item or service may require service line prior authorization? - answer- Hearing
aids
Which healthcare provider is responsible for processing and reviewing all prescriptions?
- answer- Retail Pharmacist
, What is a prior authorization? - answer- Process used to decide if a prescribed device,
procedure, service, or medication will be covered and paid for by an insurance company
or Medicare
Which of the following Medicare plans is associated with prescription drug coverage? -
answer- Medicare Part D
Mr. Smith is covered under his employer's chosen insurance coverage. Mr. Smith also
listed his wife, Mrs. Smith, and their only child, Alexis, as dependents on the plan. As a
dependent, what would Alexis's subscriber number be? - answer- 003
What is the first step in verifying insurance? - answer- Gather the information for the
provider
Which of these health insurance programs is provided specifically for uniformed service
members, retirees, and their families? - answer- TRICARE
Which of the following events is NOT considered a qualifying event for eligibility in
enrolling into COBRA?
1-New Birth
2-Job loss
3-Divorce
4-Death - answer- 1-New Birth
TRUE/FALSE. Pregnant women may be eligible for Medicaid only if they qualify
financially. - answer- TRUE
Which of the following is NOT included on the Explanation of Benefit (EOB) document
that is sent from the insurance company to the patient? - answer- CPT Codes
Which of the following services could be covered by Medicare Part A? - answer-
Hospice and skilled nursing facilities
Which of the following Medicare plans is associated with outpatient coverage? - answer-
Medicare Part B
What type of medications are covered under Medicare Part D? - answer- Only drug
formulary medications
There are federal laws and governing bodies that regulate fraud and abuse in Medicare.
Which of the following agencies enforce these laws? Select all that apply.
1-Centers for Medicare & Medicaid Services (CMS)
2-Centers for Disease Control and Prevention (CDC)
3-U.S. Department of Justice (DOJ)
4-U.S. Department of Health & Human Services (HHS) - answer- 1-Centers for
Medicare & Medicaid Services (CMS)
PROGRAM EXAM QUESTIONS
Advanced Benefits Determination - answer- Term used by the Federal Employee
Anthem Plan. A method for receiving written approval of a proposed treatment.
Authorization - answer- A detailed presentation process from the healthcare provider to
the insurance or designated review company that requires affirmation of the clinical care
plan.
Authorization Procedure - answer- The steps outlined by an individual policy to obtain
treatment approval.
Case Management Approval - answer- A self-funded insurance policy that employs a
third party to review the intended treatment. The case manager involved is typically a
nurse. This is similar to an authorization in its process and purpose but is given a
different name by the insurance company.
Case Management Treatment Notification - answer- It is required by some insurers who
use third-party oversight but is not an authorization. Medical records are given to case
management and the insurance company notifies the self-insured employer what to
expect financially. Although pricing is not typically an insurance company's
responsibility, a case manager may ask for an estimate of the cost.
Chiropractor - answer- Practices medicine relating to diagnosis and treatment of
mechanical disorders of the musculoskeletal system, specifically the spine.
Commercial Policy - answer- An insurance policy other than Medicare that may be
purchased as an independent policy or by an employee of a corporation. This type of
insurance can be bought by employees with their paychecks at work. It is rare for a self-
employed person to buy an individual policy. It is not the same as a Marketplace plan.
Consolidated Omnibus Budget Reconciliation Act (COBRA) - answer- A federal law that
allows a person and any of their immediate family members to stay on an employer-
sponsored health plan under particular circumstances
DEA Registration Number - answer- An identifier assigned to a healthcare provider (ex.
physician, optometrist, dentist, veterinarian) by the United States Drug Enforcement
Administration that allows the provider to prescribe controlled substances.
Health Insurance Marketplace - answer- Also known as Marketplace Insurance. It is a
service that helps people shop for and enroll in affordable health insurance. The federal
government operates the Marketplace and is accessible for most states via
HealthCare.gov. However, coverage through Medicaid and the Children's Health
Insurance Program (CHIP) is done by each state. The Marketplace plan follows
,guidelines of the insurance company that sold the plan. Care must be taken with
healthcare providers in-network and is it vital to monitor for changes within the plan.
Insurance Benefits - answer- The financial properties of an insurance policy. For
instance, what the policy covers and at what percentages during an enrollment period.
Why is it important to get a reference number and send a follow up letter after telephone
prior authorization? - answer- Verbal authorizations may be difficult to prove and could
be reversed
TRUE/FALSE Medicare Advantage Plans will sometimes cover routine dental services.
- answer- True
Which professional is responsible for gathering information from a patient's medical
records and submitting an authorization request to the patient's insurer? - answer-
Provider's office staff
Under the prior authorization system, who decides whether a prescribed service,
medication, procedure, or device will be paid for? - answer- Payer or Insurance
company
On average, how much time each week do physicians spend on PA related activities? -
answer- Approximately 2 days
Which healthcare provider is responsible for diagnosing the patient and prescribing a
medication that may need a PA? - answer- Submitting Provider (Clinical Staff)
A medical office just learned that a prior authorization request for a patient was rejected.
Additional information about patient needs was submitted to the insurance company,
along with an appeal. Which intake or payer-side professional will review this first level
appeal? - answer- Medical Director
Which statement about prior authorizations is true? - answer- Most payers have
different departments that process medication and service line PAs.
What is a negative impact that the Prior Authorization (PA) system has on patients? -
answer- Increased processing time can lead to abandoned therapies.
Which item or service may require service line prior authorization? - answer- Hearing
aids
Which healthcare provider is responsible for processing and reviewing all prescriptions?
- answer- Retail Pharmacist
, What is a prior authorization? - answer- Process used to decide if a prescribed device,
procedure, service, or medication will be covered and paid for by an insurance company
or Medicare
Which of the following Medicare plans is associated with prescription drug coverage? -
answer- Medicare Part D
Mr. Smith is covered under his employer's chosen insurance coverage. Mr. Smith also
listed his wife, Mrs. Smith, and their only child, Alexis, as dependents on the plan. As a
dependent, what would Alexis's subscriber number be? - answer- 003
What is the first step in verifying insurance? - answer- Gather the information for the
provider
Which of these health insurance programs is provided specifically for uniformed service
members, retirees, and their families? - answer- TRICARE
Which of the following events is NOT considered a qualifying event for eligibility in
enrolling into COBRA?
1-New Birth
2-Job loss
3-Divorce
4-Death - answer- 1-New Birth
TRUE/FALSE. Pregnant women may be eligible for Medicaid only if they qualify
financially. - answer- TRUE
Which of the following is NOT included on the Explanation of Benefit (EOB) document
that is sent from the insurance company to the patient? - answer- CPT Codes
Which of the following services could be covered by Medicare Part A? - answer-
Hospice and skilled nursing facilities
Which of the following Medicare plans is associated with outpatient coverage? - answer-
Medicare Part B
What type of medications are covered under Medicare Part D? - answer- Only drug
formulary medications
There are federal laws and governing bodies that regulate fraud and abuse in Medicare.
Which of the following agencies enforce these laws? Select all that apply.
1-Centers for Medicare & Medicaid Services (CMS)
2-Centers for Disease Control and Prevention (CDC)
3-U.S. Department of Justice (DOJ)
4-U.S. Department of Health & Human Services (HHS) - answer- 1-Centers for
Medicare & Medicaid Services (CMS)
