PACS PACS Clinical Review & Utilization Management 2

Question 1

What does 'medical necessity' generally mean in the context of prior authorization criteria?

Accepted Answer

Services that are appropriate, consistent with the diagnosis, and in accordance with accepted standards of medical practice

Answer

Any service that a physician recommends for a patient

Answer

Services that are the least expensive option available

Answer

Services that have been covered by the plan for at least five years

Question 2

A clinician reviewing a prior authorization request for a high-cost biologic drug should primarily assess which of the following?

Accepted Answer

Whether the patient has tried and failed clinically appropriate alternative therapies as required by step therapy

Answer

Whether the patient can afford the drug

Answer

Whether the prescribing physician is in-network

Answer

Whether the drug is manufactured in the United States

Question 3

What is the term for a prior authorization decision made BEFORE the patient receives the requested service or medication?

Accepted Answer

Prospective review (pre-authorization)

Answer

Concurrent review

Answer

Retrospective review

Answer

Post-payment audit

Question 4

Which of the following criteria is most commonly evaluated during a clinical review of a prior authorization request for an MRI?

Accepted Answer

Whether the patient's symptoms and clinical history meet evidence-based indications for the imaging study

Answer

The cost of the MRI at different imaging centers

Answer

Whether the ordering physician has performed MRIs in the past

Answer

Whether the patient has previously undergone physical therapy

Question 5

What is a 'non-covered service' in the context of prior authorization?

Accepted Answer

A service explicitly excluded from coverage under the patient's health plan benefits

Answer

A service that requires prior authorization but has not yet been reviewed

Answer

A service that is covered but requires step therapy first

Answer

A service that is covered for inpatient but not outpatient settings

Question 6

In utilization management, what is the significance of 'length of stay' (LOS) criteria for inpatient hospitalizations?

Accepted Answer

LOS criteria provide evidence-based benchmarks for the expected duration of inpatient care for specific diagnoses

Answer

LOS criteria help determine which physicians can admit patients to hospitals

Answer

LOS criteria determine patient co-pay amounts per hospital day

Answer

LOS criteria are used only for Medicare patients, not commercial plan members