PACS PACS Clinical Review & Utilization Management 3

Question 1

What is the purpose of a 'retrospective review' in utilization management?

Accepted Answer

To evaluate the medical necessity and appropriateness of services that have already been rendered

Answer

To authorize a service before it is provided

Answer

To predict future healthcare utilization for a patient population

Answer

To review a provider's credentials before granting network participation

Question 2

Which of the following is an example of an 'experimental or investigational' exclusion in prior authorization?

Accepted Answer

A treatment that lacks sufficient clinical evidence of safety and efficacy for the patient's condition and is not FDA-approved

Answer

A drug approved by the FDA for a specific indication being used for that same indication

Answer

A procedure that is covered under Medicare but not commercial insurance

Answer

A medication that requires a specialty pharmacy for dispensing

Question 3

A PACS professional receives a prior authorization request for a home health service. Which clinical criterion is MOST important to verify?

Accepted Answer

Whether the patient is homebound and requires skilled nursing or therapy services

Answer

Whether the home health agency accepts the patient's insurance

Answer

Whether the patient's family members can provide care instead

Answer

Whether the service was previously denied by another insurer

Question 4

What does 'clinical appropriateness' mean in the context of a prior authorization review?

Accepted Answer

The requested service is the right type, amount, and setting of care for the patient's specific clinical condition

Answer

The service is performed by a board-certified specialist

Answer

The service is available at a facility within 50 miles of the patient's home

Answer

The service has been approved by the patient's primary care physician

Question 5

Which accreditation organization sets standards for utilization management programs at health plans and managed care organizations?

Accepted Answer

The National Committee for Quality Assurance (NCQA)

Answer

The American College of Physicians (ACP)

Answer

The Drug Enforcement Administration (DEA)

Answer

The Centers for Disease Control and Prevention (CDC)

Question 6

In the context of prior authorization, what does 'level of care' determination refer to?

Accepted Answer

Determining the most appropriate and least restrictive clinical setting that meets the patient's medical needs

Answer

Determining whether a patient qualifies for Medicare or Medicaid

Answer

Assigning a diagnosis code to the patient's condition for billing purposes

Answer

Identifying which tier a drug falls under on the insurance formulary