UM 1
Compliance/Other
Model of Care
UM 2
Other
100

Notice of Authorization

What is a NOA?

100

Everyone who handles PHI is responsible.

In a healthcare setting, who is responsible for protecting patient PHI?

100

Notice of Authorization

What is a NOA?

100

Centers for Medicare & Medicaid Services

What is CMS?

100

We do not perform these at this time, but we may in the near future.

Do we conduct retrospective reviews?

200

SIP

SNF

Acute Care

IRF

LTACH

What are examples of Part A services?

200

Health Insurance Portability and Accountability Act

What does HIPAA stand for?

What is HIPAA?

200

Member 

Member Representative/POA

Prescribing Physician

Who can submit an authorization request?

200

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?

200

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?

300

Self-administered prescribed medication (i.e blood pressure medication)

What is an example of a Part D drug?

300

The health plan Medical Director

Who completes all medical necessity denials?

300

CSNP

DSNP

ISNP

IESNP

What are the 4 Special Needs Plans?

300

OT/PT/ST

DME

HH

Outpatient Services

What is an example of Part B Services?

300

By using secure passwords, encryption, and secure data storage methods.

How can you safeguard electronic PHI?

400

72 Hours

What is the TAT for Part B standard medications?

400

This refers to the adherence to laws, regulations, and ethical standards that govern the healthcare industry.

What is Healthcare Compliance?

400

They assist in managing the member's care.

What is the primary role of a Care Ally?

400

The Providers final opportunity to speak with the MD to provide supporting information to assist in medical determination.

What is a peer to peer?

400

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?

500

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?

500

The member is billed

Who gets billed if the services are not covered through the insurance plan?

500

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?

500

14 days

What ist he TAT for standard authorizations?

500

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?