CCMC Utilization Management

Question 1

What is the primary purpose of utilization management in case management?

Accepted Answer

To ensure appropriate use of healthcare resources while maintaining quality

Answer

Utilization management ensures healthcare resources are used appropriately and efficiently while maintaining quality patient care outcomes.

Question 2

Which type of utilization review involves evaluating the appropriateness of care BEFORE it is provided?

Accepted Answer

Prospective review (prior authorization)

Answer

Prospective review, also called prior authorization, occurs before care is delivered to determine medical necessity and appropriateness.

Question 3

InterQual and Milliman Care Guidelines are examples of:

Accepted Answer

Evidence-based clinical criteria used in utilization review

Answer

InterQual and Milliman Care Guidelines are evidence-based clinical criteria tools used to assess medical necessity and appropriate level of care.

Question 4

When a payer denies a claim for lack of medical necessity, the case manager's FIRST step should be to:

Accepted Answer

Review the denial reason and gather supporting clinical documentation

Answer

The first step after a denial is to review the reason and gather clinical documentation to support an appeal if appropriate.

Question 5

Concurrent utilization review is performed:

Accepted Answer

During the course of treatment or hospitalization

Answer

Concurrent review occurs during an ongoing episode of care to assess continued medical necessity and appropriateness of the current level of care.

CCMC - Commission for Case Manager Certification Practice Test