CPB (Certified Professional Biller) Certification Practice Exam

What is an authorization that must be received from a payer before treatment by a specialist will be covered?

1. Current Procedural Terminology (CPT)

2. Blue Cross Blue Shield (BCBS)

3. Preauthorization

4. ICD-9-CM

The correct answer is: Preauthorization

The correct answer is preauthorization, which is a critical step in the healthcare billing process. Preauthorization is a necessary approval obtained from a payer, such as an insurance company, to ensure that treatment by a specialist is medically necessary and will be covered under the patient's health insurance plan. This process helps to determine coverage before the patient receives specialized services, preventing unexpected out-of-pocket costs and ensuring compliance with insurance policies. Preauthorization is particularly relevant for services that may be seen as elective or expensive, as it allows the payer to assess the necessity of the proposed treatment and manage healthcare costs effectively. This step is crucial in the healthcare workflow, as it also enables providers to ascertain whether they will receive reimbursement for their services. In contrast, the other options serve different roles within the medical billing and coding realm. Current Procedural Terminology (CPT) codes are used to describe medical, surgical, and diagnostic services, whereas the ICD-9-CM codes refer to a classification system for diagnoses. Blue Cross Blue Shield (BCBS) is an insurance provider, which can itself require preauthorization for certain treatments but does not represent the concept of authorization. Each of these other choices pertains to aspects of medical coding or insurance but does not encompass the process of obtaining prior