Reimbursement and Utilization Management Flashcards
7 cards from real CCM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Reimbursement and Utilization Management flashcards as text
Which utilization management strategy involves evaluating a proposed service BEFORE it is provided to determine medical necessity?
Answer: Prospective review (prior authorization)
Prospective review, commonly known as prior authorization or pre-certification, assesses medical necessity before a service is delivered.
Which of the following best defines a 'carve-out' benefit in managed care?
Answer: A benefit excluded from the standard plan but covered under a separate specialized contract
Carve-out benefits, such as behavioral health or pharmacy, are separated from the main medical plan and managed by a specialty vendor.
Under the Mental Health Parity and Addiction Equity Act (MHPAEA), how must insurers treat mental health and substance use disorder benefits?
Answer: Mental health benefits cannot be subject to more restrictive limitations than comparable medical/surgical benefits
MHPAEA prohibits insurers from imposing more restrictive financial requirements or treatment limitations on mental health/SUD benefits than on medical/surgical benefits.
A case manager identifies that a patient is being kept in an acute care bed primarily for social reasons, not medical ones. What is the most appropriate action?
Answer: Initiate discharge planning to identify appropriate post-acute or community resources
When medical necessity for acute care no longer exists, the case manager should proactively identify appropriate placement or community supports.
What is the primary function of a formulary in pharmacy benefit management?
Answer: A tiered list of covered medications used to guide prescribing and control drug costs
A formulary is a preferred drug list organized in tiers that determines coverage level and cost-sharing for medications.
Which entity is responsible for conducting Independent Medical Reviews (IMRs) when a health plan denies a claim?
Answer: The state insurance department or a contracted independent review organization (IRO)
IMRs are conducted by independent review organizations contracted by state regulators to provide an impartial second opinion on disputed claim denials.
In the context of managed care, what does 'step therapy' require a patient to do?
Answer: Try a first-line (usually less expensive) treatment before a payer will cover a preferred or specialty medication
Step therapy protocols require patients to try and fail lower-cost treatment options before a payer will authorize more expensive alternatives.