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