UM 1
Notice of Authorization
What is a NOA?
Everyone who handles PHI is responsible.
In a healthcare setting, who is responsible for protecting patient PHI?
Notice of Authorization
What is a NOA?
Centers for Medicare & Medicaid Services
What is CMS?
We do not perform these at this time, but we may in the near future.
Do we conduct retrospective reviews?
SIP
SNF
Acute Care
IRF
LTACH
What are examples of Part A services?
Health Insurance Portability and Accountability Act
What does HIPAA stand for?
What is HIPAA?
Member
Member Representative/POA
Prescribing Physician
Who can submit an authorization request?
Process where the health plan reviews clinical information to determine whether additional requested service days are medically necessary (skilled nursing services/therapy)
What is a concurrent Review?
The acquisition, access, use, or disclosure of protected health information by a covered entity or business associate in a manner not permitted under the HIPAA Privacy Rule which compromises the security or privacy of the protected health information.
What is a PHI Breach?
Self-administered prescribed medication (i.e blood pressure medication)
What is an example of a Part D drug?
The health plan Medical Director
Who completes all medical necessity denials?
CSNP
DSNP
ISNP
IESNP
What are the 4 Special Needs Plans?
OT/PT/ST
DME
HH
Outpatient Services
What is an example of Part B Services?
By using secure passwords, encryption, and secure data storage methods.
How can you safeguard electronic PHI?
72 Hours
What is the TAT for Part B standard medications?
This refers to the adherence to laws, regulations, and ethical standards that govern the healthcare industry.
What is Healthcare Compliance?
They assist in managing the member's care.
What is the primary role of a Care Ally?
The Providers final opportunity to speak with the MD to provide supporting information to assist in medical determination.
What is a peer to peer?
Work in a private space, always lock your computer before stepping away from it.
What actions can you take to safeguard patient information in a remote setting?
Process to ensure members receive the right care at the right time in the right location; involves performance of clinical review to determine whether service is medically necessary and clinically appropriate.
What is Utilization Management?
The member is billed
Who gets billed if the services are not covered through the insurance plan?
The contract that the plan submits to CMS clearly outlining who our members are, how we take care of them, how we demonstrate that care, and howe we manage the quality of care.
What is the Model of Care?
14 days
What ist he TAT for standard authorizations?
Protected Health Information (PHI) is any information related to an individual's physical or mental health, healthcare provision, or payment for healthcare services.
What is PHI?