Certified Clinical Medical Assistant CCMA Practice Test

An MA has requested a preauthorization for a patient's referral to a specialist. Which of the following is a reason for the claim submitted by the specialist to be denied?

1. The service is not medically necessary

2. The service is provided before the authorization is obtained

3. The service is provided after the expiration date

4. The service is covered by insurance

The correct answer is: The service is provided after the expiration date

The rationale behind choosing that answer is based on the importance of adhering to the specific timelines and conditions outlined in insurance policies. If a service is provided after the expiration date of the authorization, the claim submitted by the specialist is likely to be denied because it falls outside the authorized time frame for coverage. This expiration indicates that the prior approval is no longer valid, which means the insurance will not cover the associated costs, leading to a denial of the claim. In contrast, if a service is deemed not medically necessary, is provided before authorization is obtained, or is covered by insurance, these conditions would have specific implications that might not automatically result in a claim denial—depending on other factors such as policy guidelines and the specifics of the individual's coverage. Therefore, the expiration date directly ties to a claim's denial, highlighting the critical need for timely management of referrals and authorizations in the healthcare process.