CPB Certified Professional Biller Certification Practice Exam

What must a patient obtain from a payer before seeing a specialist?

1. Referral

2. Preauthorization

3. Copayment

4. Deductible

The correct answer is: Preauthorization

The correct answer is that a patient must obtain preauthorization from a payer before seeing a specialist. Preauthorization, also known as prior authorization, is a process required by many health insurance plans that ensures the insurance company will cover services before they are provided. This is particularly common in cases involving specialists, where the insurer wants to review the necessity of the proposed service or treatment. When a patient seeks to see a specialist, the preauthorization process often involves the primary care provider submitting information to the insurance company to justify the need for the specialist's services. This process helps control costs and restricts patients from incurring unexpected expenses due to services that may not be deemed necessary by the payer. In contrast, a referral is typically the initial step in coordinating patient care but does not guarantee that the insurance company will cover the visit unless preauthorization is also secured. A copayment is an out-of-pocket fee the patient pays at the time of service, and a deductible is the amount a patient must pay for covered health care services before the insurance plan starts to pay. Neither copayment nor deductible pertain to the authorization process needed prior to visiting a specialist.