Column 1
which review type is most likely to involve discharge planning?
Concurrent review
A patient goes for surgery with pre-approval. The insurance later checks if the procedure was medically necessary. Which review type applies?
Retrospective Review
CMS, NCQA and URAC have similar turnaround time frameworks for UM decisions? True/False
True
Which of the following is a prior authorization criterion for expedited review? a) provider reference b) risk of serious harm c) type of insurance d) length of hospital stay
b) risk of serious harm
Medicare is a federal health insurance program for individuals aged 65 and older, and certain younger people with disabilities. True or False?
True
What is the main purpose of insurance?
To provide financial protection against unexpected costs
which of the following is NOT a characteristic of Prior Authorization? a) conducted before care is delivered b) ensures services are appropriate c) Used for ER admissions d) May be called precertification
c) Used for ER admissions
Scenario: A provider submits a request for urgent radiation therapy for a cancer patient. Which criterion applies, and what is the required TAT?
Urgency of required treatment; 72 hours
Which is NOT a characteristic of provider outreach? a) clarify information submitted b) Request clinical info c) Communicate determinations d) approve claims automatically
d) approve claims automatically
What is the primary purpose of Utilization Management guidelines?
To ensure care is appropriate, efficient and cost effective
Which of the following is a common reason for claim denial under UM guidelines? a) incorrect CPT code b) Provider signature on a separate page c) Missing documentation supporting medical necessity d) Using an electronic health record
c) Missing documentation supporting medical necessity
You receive a prior authorization request on Friday 4pm. When does the TAT clock start?
Friday at 4pm
LCDs apply nation wide and override NCDs. True or False?
False
What tool can help flag services requiring NCD/LCD checks before submission?
EHR alerts
Which of the following is NOT part of the steps to apply NCDs and LCDs effectively? a) coverage determination b) check coverage criteria c) Ensure correct coding d) Negotiate provider reimbursement rates
d) Negotiate provider reimbursement rates
Why is correct coding critical under UM guidelines?
It ensures claims are paid promptly and prevents denials
Which managed care plan guarantees coverage for out-of-network providers without any extra cost?
None
Which tools are commonly used to support clinical decisioning?
InterQual and MCG
Medicaid is offered by state government only? True or False
False
The following are protected health information except one. a) address b) medical records c) education records d) Laboratory results
c) education records
What is the purpose of McKesson InterQual criteria?
To support medical necessity and level-of-care decisions
Which of the following BEST describes Milliman Care Guidelines (MCG)? a) a tool to determine reimbursement rates b) Evidence based guidelines emphasizing care pathways and discharge planning c) A coding system for Medicare claims d) a federal regulation for managed care organizations
b) Evidence based guidelines emphasizing care pathways and discharge planning
What is the primary purpose of InterQual Criteria in healthcare?
To assess medicla necessity and appropriate level of care
The following are true in understanding NCD except for one. a) Plan benefit b) coverage summary c) Indications and limitations of coverage d) covered ICD-10 codes
a) Plan benefit
What does HITCH stand for?
Health information Technology for Economic and Clinical Health Act