TMIPA UM Jeopardy

Utilization Management

100

UM stands for this.

Utilization Management

200

This review is done AFTER services have been provided.

Retrospective Review

300

This referral status means the requested services meets applicable guidelines.

Approved

400

This turnaround time is 24 hours from date and time of receipt.

Pharmacy (Part B) Urgent

500

Names of all the Health Plans managed by UM.

Aetna

Anthem Blue Cross

Blue Shield

Cigna

Health Net

Humana

UHC

SCAN

People in UM

100

This person is responsible for conducting oral notifications and inputting data entry requests

Charolette

200

This group of people are responsible for non-clinical support, benefit checks, ensuring clinical records are available for processing, and responding to referral inquiries.

Coordinators

300

This person provides staff education, monitors daily compliance, and outreach to the team to ensure the department is within turnaround time

Janette

400

This person is responsible for appeal triage, transplant reviews, and decision letter writing

Vianna

500

This person manages 2 utilization management departments & also a workers compensation department.

Jeff

Thanksgiving

100

Day of the week Thanksgiving falls on

Thursday

200

This shopping day follows Thanksgiving

Black Friday

300

This orange fruit is commonly carved out for Halloween and also used in popular pie served at Thanksgiving

Pumpkin

400

This famous cartoon dog celebrates Thanksgiving with Charlie Brown

Snoopy

500

True or False: we have Thanksgiving off

True

People in Care Coordination

100

This person is responsible for Contracting providers and establishing Letter of Agreement's for medically necessary Out of Network requests.

Matt

200

This person is responsible for provider relations (office education and outreach)

Tania

300

This nurse manages patients who are admitted at out of network facilities.

Hint: she used to be part of our UM team

Nakaia 

400

VP of Value Based Care

Yumi 

500

This person shares the same first name with 2 other people in Care Coordination

Michelle

Utilization Management 2

100

This review occurs BEFORE services are being rendered

Prior Authorization/Pre-Service

200

This type of check is needed when a request for an OON provider is going to be approved.

Hint: done by credentialing.

Sanction Check

300

This third-party evaluator is used to determine if a high-cost DME is medically necessary

Periscope

400

This person is who the nurse sends referral reviews to when it cannot be approved or requires higher level review.

Medical Director

500

This line of business does not observe Holidays

CMS/Medicare