Fundamental Before the Prior Auth

Question 1

TRUE/FALSE Even if your organization has assigned medical coders it is still important for a Prior Authorization Specialist to understand coding because most coders work with medical records after treatment, while authorizers need those codes before treatment.
* TRUE
* FALSE

Answer 1

True

Question 2

What information should be included in a prior authorization claim? Select all that apply:
* Diagnosis (ICD-10 code)
* Weight (kg or lb)
* Height (cm or in)
* For some specialty medications: PPD Test
* Identification of status of treatment such as continuation of therapy response to prior therapy if continuation
* Site of administration (if applicable)Identification of status of treatment such as new therapy
* Outdated patient medication history that does not include over-the-counter medications
* Previous drug trials (use of a similar drug)

Answer 2

All except “outdated patient med history”

Question 3

For which of the following are ICD-10 codes used? Select all that apply:
* processing insurance claims
* aid in physician documentation
* tracking treatment options
* tracking disease epidemics

Answer 3

Processing insurance claims and tracking disease epidemics

Question 4

The structure of a(n)_______ requires the application of fundamental skills and information.
* insurance claim
* ICD-10 codes
* prior authorization
* substantiated medical records

Answer 4

prior authorization

Question 5

When evaluating a medically accepted indication in a drug compendium, the user must also look at the _______ if the drug is used off-label.
* level of efficacy
* appropriateness of use
* medical notes
* drug ranking in comparison to on-label indications

Answer 5

level of efficacy

Question 6

TRUE/FALSE Insurance plans are variable regarding the information needed for prior authorization, but there are some consistencies for certain diagnoses and disease states.
* TRUE
* FALSE

Answer 6

True

Question 7

TRUE/FALSE It is NOT considered good practice for Prior Authorization specialists to utilize so-called “cheat sheets” for coding.
* TRUE
* FALSE

Answer 7

False

Question 8

______________ may include drug interactions, adverse reactions, uses in specific disease states, dosages, and pharmacology.
* Medical records
* Drug compendia
* FDA approval list
* Drug inserts

Answer 8

Drug compendia

Question 9

You have received a medical record where the ICD-10 code is M80.051A. What information should be in the medical record to substantiate the use of the A?
* the treating physician’s initial is A
* this is an initial encounter
* this is the left leg
* this is a subsequent encounter with delayed healing

Answer 9

this is an initial encounter

Question 10

Who is responsible for the updating, revision, and general maintenance of ICD related codes?
* the ICD board of maintenance
* HHS
* the CDC
* the WHO

Answer 10

WHO