PACS Clinical Review & Utilization Management Flashcards

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

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

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

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

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

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.

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

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

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.

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

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

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.

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

Answer: The National Committee for Quality Assurance (NCQA)

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

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

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

Level of care determination identifies the most appropriate and least restrictive clinical setting — such as inpatient, partial hospitalization, or outpatient — that adequately meets the patient's medical needs.