Utilization Management Flashcards

What does 'level of care' determination refer to in utilization management?

Answer: The assessment of the appropriate care setting based on a patient's clinical needs

Level of care determination assesses whether a patient requires inpatient, observation, skilled nursing, or outpatient care based on clinical criteria.

Under the utilization management process, 'medical necessity' is BEST defined as:

Answer: Care that is clinically appropriate, evidence-based, and required to diagnose or treat a condition

Medical necessity refers to care that is clinically appropriate and evidence-based, required to diagnose or treat a condition, and not primarily for convenience.

Retrospective utilization review is MOST useful for:

Answer: Identifying patterns of over- or under-utilization after care is delivered

Retrospective review analyzes care that has already occurred to identify utilization patterns, billing accuracy, and potential overuse or underuse of services.

Which federal law requires health plans to establish an internal and external appeals process for denied claims?

Answer: The Affordable Care Act (ACA)

The ACA mandates that health plans provide both internal and external appeals processes for denied or terminated coverage decisions.

In utilization management, discharge planning should ideally begin:

Answer: At the time of admission or as early in the stay as possible

Effective discharge planning begins at admission or as early as possible to identify post-acute needs and ensure a safe, timely care transition.

A case manager conducting utilization review identifies that a patient's inpatient stay no longer meets medical necessity criteria. The BEST course of action is to:

Answer: Notify the treating physician and collaboratively discuss appropriate transition options

The case manager should communicate findings to the treating physician collaboratively to facilitate an appropriate and safe level of care transition.

Which of the following BEST describes 'observation status' in hospital utilization management?

Answer: An outpatient status where patients receive monitoring while inpatient criteria are evaluated

Observation status is an outpatient classification billed under Medicare Part B, used when patients require monitoring but do not meet inpatient admission criteria.