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

Retrospective review evaluates the medical necessity and appropriateness of services that have already been provided, often affecting payment decisions.

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

Experimental or investigational exclusions apply to treatments lacking sufficient evidence of safety and efficacy or not approved by the FDA for the patient's specific condition.

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

For home health services, the most critical clinical criterion is verifying that the patient is homebound and requires skilled nursing or therapy services per plan and Medicare guidelines.

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

Clinical appropriateness means the requested service is the right type, amount, intensity, and setting of care for the patient's specific clinical condition based on evidence-based standards.

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 NCQA sets the accreditation standards for utilization management programs at health plans and managed care organizations through its Health Plan Accreditation program.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS PACS Clinical Review & Utilization Management 3