PACS PACS Clinical Review & Utilization Management 2 — Questions and Answers
Question 1: What does 'medical necessity' generally mean in the context of prior authorization criteria?
- Any service that a physician recommends for a patient
- Services that are appropriate, consistent with the diagnosis, and in accordance with accepted standards of medical practice (Correct answer)
- Services that are the least expensive option available
- Services that have been covered by the plan for at least five years
Correct answer: Services that are appropriate, consistent with the diagnosis, and in accordance with accepted standards of medical practice
Medical necessity refers to services that are appropriate, consistent with the patient's diagnosis, and in accordance with accepted standards of medical practice.
Question 2: A clinician reviewing a prior authorization request for a high-cost biologic drug should primarily assess which of the following?
- Whether the patient can afford the drug
- Whether the patient has tried and failed clinically appropriate alternative therapies as required by step therapy (Correct answer)
- Whether the prescribing physician is in-network
- Whether the drug is manufactured in the United States
Correct answer: Whether the patient has tried and failed clinically appropriate alternative therapies as required by step therapy
For high-cost biologics, the clinical reviewer primarily assesses whether the patient has tried and failed appropriate step therapy alternatives before approving the biologic.
Question 3: What is the term for a prior authorization decision made BEFORE the patient receives the requested service or medication?
- Concurrent review
- Retrospective review
- Prospective review (pre-authorization) (Correct answer)
- Post-payment audit
Correct answer: Prospective review (pre-authorization)
A prospective review, also called pre-authorization, is a utilization management decision made before the patient receives the requested service or medication.
Question 4: Which of the following criteria is most commonly evaluated during a clinical review of a prior authorization request for an MRI?
- The cost of the MRI at different imaging centers
- Whether the patient's symptoms and clinical history meet evidence-based indications for the imaging study (Correct answer)
- Whether the ordering physician has performed MRIs in the past
- Whether the patient has previously undergone physical therapy
Correct answer: Whether the patient's symptoms and clinical history meet evidence-based indications for the imaging study
Clinical review of an MRI authorization evaluates whether the patient's symptoms and clinical history meet the evidence-based indications established in UM criteria guidelines.
Question 5: What is a 'non-covered service' in the context of prior authorization?
- A service that requires prior authorization but has not yet been reviewed
- A service explicitly excluded from coverage under the patient's health plan benefits (Correct answer)
- A service that is covered but requires step therapy first
- A service that is covered for inpatient but not outpatient settings
Correct answer: A service explicitly excluded from coverage under the patient's health plan benefits
A non-covered service is one that is explicitly excluded from a patient's health plan benefits, and prior authorization cannot override benefit exclusions.
Question 6: In utilization management, what is the significance of 'length of stay' (LOS) criteria for inpatient hospitalizations?
- LOS criteria help determine which physicians can admit patients to hospitals
- LOS criteria provide evidence-based benchmarks for the expected duration of inpatient care for specific diagnoses (Correct answer)
- LOS criteria determine patient co-pay amounts per hospital day
- LOS criteria are used only for Medicare patients, not commercial plan members
Correct answer: LOS criteria provide evidence-based benchmarks for the expected duration of inpatient care for specific diagnoses
Length of stay criteria provide evidence-based benchmarks for expected inpatient duration by diagnosis, guiding concurrent review and authorization for continued hospital stays.
PACS PACS Clinical Review & Utilization Management 2
What does 'medical necessity' generally mean in the context of prior authorization criteria?