PRIOR AUTHORIZATION
CERTIFIED SPECIALIST PROGRAM
EXAM QUESTIONS
Question 1: Why is it important to get a reference number and
send a follow up letter after telephone prior authorization?
CORRECT ANSWER : Verbal authorizations may be
difficult to prove and could be reversed
Question 2: TRUE/FALSE Medicare Advantage Plans will
sometimes cover routine dental services.
CORRECT ANSWER : True
Question 3: Which professional is responsible for gathering
information from a patient's medical records and submitting an authorization request to the patient's insurer?
CORRECT ANSWER : Provider's office staff
Question 4: Under the prior authorization system, who
decides whether a prescribed service, medication, procedure, or device will be paid for?
CORRECT ANSWER : Payer or Insurance company
Question 5: On average, how much time each week do
physicians spend on PA related activities?
CORRECT ANSWER : Approximately 2 days
Question 6: Which healthcare provider is responsible for
diagnosing the patient and prescribing a medication that may need a PA?
CORRECT ANSWER : Submitting Provider (Clinical Staff)
Question 7: 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?
CORRECT ANSWER : Medical Director
Question 8: Which statement about prior authorizations is
true?
CORRECT ANSWER : Most payers have different
departments that process medication and service line PAs.
Question 9: What is a negative impact that the Prior
Authorization (PA) system has on patients?
CORRECT ANSWER : Increased processing time can lead
to abandoned therapies.
Question 10: Which item or service may require service line
prior authorization?
CORRECT ANSWER : Hearing aids
Question 11: Which healthcare provider is responsible for
processing and reviewing all prescriptions?
CORRECT ANSWER : Retail Pharmacist
Question 12: What is a prior authorization?
CORRECT 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
Question 13: Which of the following Medicare plans is
associated with prescription drug coverage?
CORRECT ANSWER : Medicare Part D
Question 14: 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?
CORRECT ANSWER : 003
Question 15: What is the first step in verifying insurance?
CORRECT ANSWER : Gather the information for the
provider
Question 16: Which of these health insurance programs is
provided specifically for uniformed service members, retirees, and their families?