PACS TESTBANK QUESTIONS WITH
100% CORRECT ANSWERS
Which outpatient service helps people with a physical, sensory, or cognitive disability
become as independent as possible in all areas of their lives? - Answer- occupational
therapy
Which diagnostic radiology exam is used to diagnose upper GI diseases by obtaining
images of motion? - Answer- fluoroscopy
Mr. Virgil has prostate cancer. His insurance wants him to use a radiology clinic near his
home that specializes in breast cancer. Even though this Dr. is trained in both types of
cancer radiation Mr. Virgil states he would prefer to use a different physician. When
reaching out to the insurance company, what is the best course of action? Select all that
apply
-make sure the insurance company acknowledges that even though the radiologist is
trained in prostate cancer the clinic does not regularly practice this type of radiology and
is not equipped to deal with this type of treatment
-don't call the insurance company at all since you now know this radiologist is trained in
both prostate cancer and breast cancer treatment
-tell the insurance company how stupid they are for not acknowledging the differences
between a breast and a prostate
-make a strong case for Mr. Virgil, stressing his particular needs - Answer- -make sure
the insurance company acknowledges that even though the radiologist is trained in
prostate cancer the clinic does not regularly practice this type of radiology and is not
equipped to deal with this type of treatment
-make a strong case for Mr. Virgil, stressing his particular needs
What is a Step Process?
Insurance verification information
The total distance between the patient's home and in-network facility
Layers of testing that must be done before others
CPT codes assigned to the imaging study - Answer- layers of testing that must be done
before others
,What is a Network Status?
Payment based on patient in-network cost
Financial contract between the patient and insurance companies
Payment based on patient out-of-network cost
Financial contract between the insurer and the facility or the insurer and the physician -
Answer- Financial contract between the insurer and the facility or the insurer and the
physician
When can an Out-of-Network Waiver be approved?
The network provider is experienced with the diagnosis
The network provider is board-certified
The distance at the provider site is less than 50 miles from the patient home
Treatment is only available at the requested site - Answer- Treatment is only available
at the requested site
TRUE/FALSE It is the responsibility of the authorizer to know how reduced
circumstances will affect the payment of claims. - Answer- True
If an out-of-network form is not available and the authorizer needs to write a letter,
which of the following steps should be taken? Select all that apply.
Call the provider line to get a fax number or email address
Research and document the need for an out-of-network waiver
Write a letter that includes all the pertinent information
Create an out-of-network form - Answer- Call the provider line to get a fax number or
email address
Research and document the need for an out-of-network waiver
Write a letter that includes all the pertinent information
The goal of the authorization is to receive approval from the insurance company. To
gain that approval, the authorizer needs to:
Prove that the request meets the insurance company's guidelines
Ask the provider to give treatment information
Require the patient to navigate the insurance company websites
Not include the insurance company in the medical records submission - Answer- Prove
that the request meets the insurance company's guidelines
If a potential error is made by the insurance company, what can the authorizer do to
correct this situation?
Submit an in-network request
Submit an out-of-network request
Call the insurance company and make a strong case for the patient
Explain the situation to the patient - Answer- Call the insurance company and make a
strong case for the patient
Gayle is an 86-year-old woman living in a care facility in a rural area of Nebraska due to
a broken hip. She is in need of a surgical procedure that can be provided at an
, outpatient surgery center her physician recommends which is about 20-minutes from
her home. Unfortunately, since that center is out-of-network the insurance company is
suggesting an alternative facility that is 50 minutes from her home. The physician would
like to perform the surgery ASAP but since it is currently January in Nebraska, Gayle's
daughter is concerned about the road conditions that time of year. What are some
reasons a network appeal might be successful for Gayle? Select all that apply
needs surgery soon
winter roads
mobility issues
physician recommendation
distance - Answer- needs surgery soon
winter roads
mobility issues
distance
A waiver of network status is sometimes referred to as a:
Gap Waiver
Out-of-Network Request form
Network Waiver
Waiver Request - Answer- gap waiver
A Non-Formulary Exception Request can be approved based on the following criteria:
The provider has sent in supporting documents indicating that the formulary alternatives
were as effective as the requested drug
The provider has documented that the patient has a tolerance to two or more formulary
drugs
The patient was successful at the number of formulary drugs required from the
formulary alternative list
Paid claims for medications tried on the formulary - Answer- Paid claims for medications
tried on the formulary
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? - Answer- medical director
Which healthcare provider is responsible for diagnosing the patient and prescribing a
medication that may need a PA? - Answer- Submitting Provider (Clinical staff)
What is a negative impact that the PA system has on patients? - Answer- Increased
processing time can lead to abandoned therapies
On average, how much time each week do physicians spend on PA related activities? -
Answer- approx 2 days
100% CORRECT ANSWERS
Which outpatient service helps people with a physical, sensory, or cognitive disability
become as independent as possible in all areas of their lives? - Answer- occupational
therapy
Which diagnostic radiology exam is used to diagnose upper GI diseases by obtaining
images of motion? - Answer- fluoroscopy
Mr. Virgil has prostate cancer. His insurance wants him to use a radiology clinic near his
home that specializes in breast cancer. Even though this Dr. is trained in both types of
cancer radiation Mr. Virgil states he would prefer to use a different physician. When
reaching out to the insurance company, what is the best course of action? Select all that
apply
-make sure the insurance company acknowledges that even though the radiologist is
trained in prostate cancer the clinic does not regularly practice this type of radiology and
is not equipped to deal with this type of treatment
-don't call the insurance company at all since you now know this radiologist is trained in
both prostate cancer and breast cancer treatment
-tell the insurance company how stupid they are for not acknowledging the differences
between a breast and a prostate
-make a strong case for Mr. Virgil, stressing his particular needs - Answer- -make sure
the insurance company acknowledges that even though the radiologist is trained in
prostate cancer the clinic does not regularly practice this type of radiology and is not
equipped to deal with this type of treatment
-make a strong case for Mr. Virgil, stressing his particular needs
What is a Step Process?
Insurance verification information
The total distance between the patient's home and in-network facility
Layers of testing that must be done before others
CPT codes assigned to the imaging study - Answer- layers of testing that must be done
before others
,What is a Network Status?
Payment based on patient in-network cost
Financial contract between the patient and insurance companies
Payment based on patient out-of-network cost
Financial contract between the insurer and the facility or the insurer and the physician -
Answer- Financial contract between the insurer and the facility or the insurer and the
physician
When can an Out-of-Network Waiver be approved?
The network provider is experienced with the diagnosis
The network provider is board-certified
The distance at the provider site is less than 50 miles from the patient home
Treatment is only available at the requested site - Answer- Treatment is only available
at the requested site
TRUE/FALSE It is the responsibility of the authorizer to know how reduced
circumstances will affect the payment of claims. - Answer- True
If an out-of-network form is not available and the authorizer needs to write a letter,
which of the following steps should be taken? Select all that apply.
Call the provider line to get a fax number or email address
Research and document the need for an out-of-network waiver
Write a letter that includes all the pertinent information
Create an out-of-network form - Answer- Call the provider line to get a fax number or
email address
Research and document the need for an out-of-network waiver
Write a letter that includes all the pertinent information
The goal of the authorization is to receive approval from the insurance company. To
gain that approval, the authorizer needs to:
Prove that the request meets the insurance company's guidelines
Ask the provider to give treatment information
Require the patient to navigate the insurance company websites
Not include the insurance company in the medical records submission - Answer- Prove
that the request meets the insurance company's guidelines
If a potential error is made by the insurance company, what can the authorizer do to
correct this situation?
Submit an in-network request
Submit an out-of-network request
Call the insurance company and make a strong case for the patient
Explain the situation to the patient - Answer- Call the insurance company and make a
strong case for the patient
Gayle is an 86-year-old woman living in a care facility in a rural area of Nebraska due to
a broken hip. She is in need of a surgical procedure that can be provided at an
, outpatient surgery center her physician recommends which is about 20-minutes from
her home. Unfortunately, since that center is out-of-network the insurance company is
suggesting an alternative facility that is 50 minutes from her home. The physician would
like to perform the surgery ASAP but since it is currently January in Nebraska, Gayle's
daughter is concerned about the road conditions that time of year. What are some
reasons a network appeal might be successful for Gayle? Select all that apply
needs surgery soon
winter roads
mobility issues
physician recommendation
distance - Answer- needs surgery soon
winter roads
mobility issues
distance
A waiver of network status is sometimes referred to as a:
Gap Waiver
Out-of-Network Request form
Network Waiver
Waiver Request - Answer- gap waiver
A Non-Formulary Exception Request can be approved based on the following criteria:
The provider has sent in supporting documents indicating that the formulary alternatives
were as effective as the requested drug
The provider has documented that the patient has a tolerance to two or more formulary
drugs
The patient was successful at the number of formulary drugs required from the
formulary alternative list
Paid claims for medications tried on the formulary - Answer- Paid claims for medications
tried on the formulary
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? - Answer- medical director
Which healthcare provider is responsible for diagnosing the patient and prescribing a
medication that may need a PA? - Answer- Submitting Provider (Clinical staff)
What is a negative impact that the PA system has on patients? - Answer- Increased
processing time can lead to abandoned therapies
On average, how much time each week do physicians spend on PA related activities? -
Answer- approx 2 days
