PriorAuthorization Flashcards
List four general points of data that the payer will accept searches by.
Member ID, Date of Birth, First Name, Last Name
A message format that allows us to electronically exchange informations between organizations
X12 message
This character is used to separate segments in X12 messages
Asterisk “*”
271 is ….?
a payer’s response to a 270
An Eligibility Benefit Inquiry, the message sent to a payer to determine a patient’s eligibility for benefits is referred to as a ….
270
A payer’s response to an Eligibility Benefit Inquiry is referred to as …
a 271
The communication sent to a payer to request prior authorization for a patient is referred to as
278R
A 278R does what?
Initiates a request to the payer requesting prior authorization approval
What type of syntax is utilized for X12 communication?
delimited
List three outcomes to a prior authorization submission
Payer unable to accept
Unable to submit to payer
Payer response
After submitting a prior authorization and having received a payer response, what are five possible responses?
Declined Approved Prior Authorization not need Pending for further review Duplicate request
You’ve submitted a prior authorization to the payer and you’re getting a message “error in submit”, what is the Olive term for this?
Payer unable to accept
You’re attempting to submit a prior authorization to a payer and it’s unable to submit. What is the Olive term for this?
Unable to submit to payer
If a payer returns a 271 indicating that coverage does not exist for the patient, how would you go about getting the prior authorization approved?
You cannot, no submissions would be allowe.
After checking and receiving confirmation of a patient’s eligibility, you the compile a _____ by completing the fields necessary to send a 278R to the payer.
draft
