CCMC Utilization Management 2

Question 1

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

Accepted Answer

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

Answer

The quality star rating assigned to a hospital facility

Answer

The financial tier of the patient's insurance coverage

Answer

The education level required for case managers practicing UM

Question 2

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

Accepted Answer

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

Answer

Any treatment requested by the patient or family

Answer

The most comprehensive and expensive available treatment option

Answer

Any treatment listed as covered under the patient's insurance plan

Question 3

Retrospective utilization review is MOST useful for:

Accepted Answer

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

Answer

Approving services before they are rendered to the patient

Answer

Monitoring ongoing inpatient stays for continued necessity

Answer

Preventing unnecessary hospitalizations before they occur

Question 4

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

Accepted Answer

The Affordable Care Act (ACA)

Answer

HIPAA (Health Insurance Portability and Accountability Act)

Answer

COBRA (Consolidated Omnibus Budget Reconciliation Act)

Answer

ERISA (Employee Retirement Income Security Act)

Question 5

In utilization management, discharge planning should ideally begin:

Accepted Answer

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

Answer

On the day of discharge once all services are completed

Answer

After the patient formally requests discharge planning services

Answer

Only after the attending physician writes a formal discharge order

Question 6

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:

Accepted Answer

Notify the treating physician and collaboratively discuss appropriate transition options

Answer

Immediately discharge the patient without consulting the care team

Answer

Continue the stay without documenting or reporting the finding

Answer

Contact the patient's family directly to demand they arrange discharge

Question 7

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

Accepted Answer

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

Answer

A form of inpatient admission fully covered under Medicare Part A

Answer

A designation reserved exclusively for psychiatric patients

Answer

A billing code used only by private commercial insurers