Prior Auth Process

Question 1

Which HCP is responsible for diagnosing the pt. and prescribing a medication that may need a PA?
a. Prior Auth Pharmacist (insurance side)
b. Submitting provider (office staff)
c. Submitting provider (clinical staff)
d. Retail pharmacist

Answer 1

submitting provider (clinical staff)

Question 2

2. On average, how much time each week to physicians spend on PA related activities?
   a. Appx. 10 minutes
   b. Apps. 5 days
   c. Appx 2 days
   d. Appx 1 hours

Answer 2

Appx. 2 days

Question 3

3. Under the prior auth system, who decides whether a prescribed service, medication, procedure, or device will be paid?
   a. Prescribing physician
   b. Patient
   c. Pharmacist
   d. Payer or insurance company

Answer 3

payer or insurance company

Question 4

4. Which professional is responsible for gathering info from a patient’s medical records and submitting an auth request to the patient’s insurer?
   a. Prior auth intake rep
   b. Specialty pharmacy
   c. Providers office staff
   d. Medical director (intake side)

Answer 4

Providers office staff

Question 5

5. Which HCP is responsible for processing and reviewing all prescriptions?
   a. Prior Auth pharmacist (insurance side)
   b. Submitting provider (clinical staff)
   c. Submitting provider (office staff)
   d. Retail pharmacist

Answer 5

Retail Pharmacist

Question 6

6. What is a prior auth?
   a. Process used to decide if a physician is qualified to prescribe a specific, device, procedure, service, or medication
   b. Process used to decide if a pt should be prescribed a necessary device, procedure, service, or medication
   c. Process used to decide if a prescribed device, procedure, service, or med will be covered and paid for by an insurance company or Medicare
   d. Process used to decide if over-the-counter meds will be covered and paid for by an insurance company or Medicare

Answer 6

Process used to decide if a prescribed device, procedure, service, or med will be covered and paid for by an insurance company or Medicare.

Question 7

Which statement about prior auths is true?
a. Pharmacists and pharmacy techs typically process service line PA’s
b. The pts physician approved service line Pas for payment
c. The forms used for service line and medications Pas are the same
d. Most payers have different departments that process med and service line Pas

Answer 7

Most payers have different departments that process med and service line Pas

Question 8

8. What is a negative impact that the PA system has on pts.?
   a. Pts. Receive high quality service in a short amount of time
   b. Prescribed medication is safe and appropriate for the medical condition
   c. Increased processing time can lead to abandoned therapies
   d. Authorization requests decrease the average pt wait time.

Answer 8

Increased processing time can lead to abandoned therapies

Question 9

9. A medical office just learned that a PA request for a pt. was rejected. Additional info about patient needs was submitted to the insurance company, along with an appeal. Which intake or payer-side professional will receive this 1st level appeal?
   a. Medical Director
   b. Prior Auth intake representative
   c. Insurance pre-auth specialist
   d. Prior auth review nurse

Answer 9

medical director

Question 10

10. Which item or service may require service line PA
    a. Hearing aids
    b. Infusion drugs
    c. Opioids
    d. Prescription medications

Answer 10

hearing aids