PACS Clinical Review & Utilization Management Flashcards

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

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.

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

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.

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

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.

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

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.

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

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.

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

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.