Level 2 - Authorizations
Quiz by Ashley Jones
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- Q1
Angela contacts us to request home healthcare. She is having surgery in 2 weeks, and will need care during her recovery. Angela wants to ensure everything is scheduled ahead of going in for surgery. As an ICR, you complete your research and confirm the following: An auth for surgery on file is approved and valid for three months, however, there is no auth on file for home healthcare services. How would you handle this situation?
Verify in DME portal if a referral has been submitted. Contact PCP and advise of home healthcare request. Determine if coordination of care is needed and initiate standard org determination.
Contact the PCP to ensure that home healthcare is needed for the type of surgery Angela is having. If so, initiate an expedited org determination on behalf of the member.
Verify in DME portal if a script/order has been submitted. Contact PCP and advise of home healthcare request. Determine if coordination of care is needed and initiate standard org determination.
Verify in DME portal if a script/order has been submitted. Contact PCP and advise of home healthcare request. Determine if coordination of care is needed and initiate an expedited org determination.
60s - Q2
An ICR receives a call from a DOH on 08/30/21 who confirms the following:
"It's eleven fifty in the morning and I am hoping you can assist me. My sister has dialysis treatments scheduled three times a week as she was diagnosed with ESRD back in late July. She completed her first three dialysis treatments last week, however, I received a call from DaVita telling me that they did not have the approval on file for next week's visits. They did clarify everything is good to go for this week."
As the ICR, you proceed to conduct your research and confirm the following: The authorization on file has been exhausted since the member used it for last week's visits. Dr. Gomez (PCP) submitted an expedited authorization request for three months work of dialysis treatments which is in pending status on 08/30/21 at 9:36am.
Based on the above scenario, what STC would you use to document the call interaction in regard to research and resolution?
C0182
CP196
C0259
C0099
120s - Q3
What resource can you use to determine if a Part B medication requires a Coverage Determination or an Org Determination?
IHCS Portal
CDAG/ODAG
Par Provider Grid
PA Hub
30s - Q4
What steps would you take for the following scenario: A member calls in upset that her PCP has still not submitted an authorization request for her to see Dr. Kline, a neurologist. She has called her PCP's office numerous times, and now has to reschedule her neurology appointment which was scheduled over 2 months ago.
Open a standard Org Determination request
Open an expedited Org Determination request
File an Access grievance and open an Org Determination request
File a Quality of Service grievance and open an Org Determination request
60s - Q5
Sherilyn called into Member Services to inquire after the status of her doctor's request for her to have CPHP authorization her obtaining a power wheelchair. You research the account and notice the authorization request has been denied. You further find that a denial letter has been generated just yesterday. How do you assist Sherilyn?
Advise Sherilyn of the denial and her appeal rights
Open a new Org Determination
Advise Sherilyn she will need to follow up with her PCP to provide additional medical notes for CPHP to review
File a grievance for Sherilyn
60s - Q6
How long does CarePlus have to make a determination on a standard Org Determination request?
As expeditiously as the member's health requires, but no later than 14 business days
As expeditiously as the member's health requires, but no later than 14 calendar days
As expeditiously as the member's health requires, but no later than 30 calendar days
As expeditiously as the member's health requires, but no later than 7 calendar days
60s - Q7
What does HSO stand for?
Users enter free textType an Answer45s - Q8
Link the following terms to their definition:
Users link answersLinking120s - Q9
Match the authorization abbreviations.
Users link answersLinking120s - Q10
What is the status of the auth shown?
Denied
Approved
Pending
Voided
120s - Q11
Which line shows an approved in-patient authorization?
10
8
6
7
30s - Q12
What listed vendor was authorized to provide the member transportation?
Access2Care
Allied Mobile
Independent
Palm Bch Diabetes
30s - Q13
What is the expiration date of the shown authorization? (Use date format MM-DD-YY)
Users enter free textType an Answer30s - Q14
What is the date the shown authorization was received by CarePlus? (Use date format MM-DD-YY)
Users enter free textType an Answer30s - Q15
What is the CPT code number for the shown authorization?
Users enter free textType an Answer30s
