Utilization review process and medical necessity criteria concepts tested on the CCM certification exam.
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- What is the primary purpose of utilization review (UR)?
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To evaluate the medical necessity, appropriateness, and efficiency of health care services.- What is prospective review?
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UR performed before a service is delivered, such as prior authorization.- What is concurrent review?
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UR performed while care is actively being delivered, such as reviewing an ongoing hospital stay.- What is retrospective review?
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UR performed after a service has already been provided.- Define medical necessity.
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Health care services or supplies needed to diagnose or treat an illness or injury, consistent with accepted standards of medical practice.- What is InterQual?
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A widely used set of evidence-based clinical decision support criteria for determining medical necessity and appropriate level of care.- What are MCG guidelines (formerly Milliman Care Guidelines)?
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Another evidence-based criteria set used to determine medical necessity and the appropriate care setting.- What is a peer-to-peer review?
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A discussion between the treating physician and the health plan's physician reviewer about a medical necessity determination.- What is an adverse determination?
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A decision by a health plan that a requested service is not medically necessary or not covered.- What is a first-level appeal?
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The initial internal request to a health plan to reconsider an adverse determination.- What is a second-level appeal?
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A further internal review of an adverse determination after a first-level appeal is upheld.- What is an external review?
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A review of an adverse determination conducted by an independent party outside the health plan, after internal appeals are exhausted.- When is an expedited appeal used?
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When following the standard appeal timeline could seriously jeopardize the patient's health.- What does URAC accredit?
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Organizations performing utilization review and other health care quality functions.- What does NCQA accredit?
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Health plans and managed care organizations, focusing on quality management standards.
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