Many health plans use clinical pathways to help manage the delivery of acute care services to plan members. One true statement about clinical pathways is that they
Maxwell Midler’s health plan operates a drug formulary that includes a typical three-tier copayment structure with required copayments of $5, $10, and $25. Mr. Midler recently filled a prescription for a $75 drug that was not included in the formulary. According to the plan’s formulary copayment structure, the amount that Mr. Midler was required to pay for his prescription was
The Shoreside Health Plan recently added coverage for behavioral healthcare services to its benefit package. In order to support the quality of its behavioral healthcare services, Shoreside plans to seek accreditation for its behavioral healthcare program. Accreditation specifically designed for behavioral healthcare programs is available through
1. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
2. The National Committee for Quality Assurance (NCQA)
3. The American Accreditation HealthCare Commission/URAC (URAC)
The Garnet Health Plan uses provider profiling to measure and improve provider performance. Provider profiling most likely allows Garnet to
Health plans have a specified number of working days to respond to Level One appeals, as stated by company policy or regulatory requirements. With regard to the timeframes for appeals, it is generally correct to say
1. That the typical timeframe requires a health plan to respond to appeals in fewer than 20 days
2. That the timeframe is accelerated for expedited appeals
3. That the review period begins when the appeal arrives at a health plan
Examples of alternative healthcare practitioners are chiropractors, naturopaths, and acupuncturists. The only well-established credentialing standards for alternative healthcare practitioners are those available from NCQA. These NCQA credentialing standards apply to
Health plans communicate proposed performance changes through action statements. Select the answer choice containing an action statement that includes all of the required elements.
To see that utilization guidelines are consistently applied, UR programs rely on authorization systems. Determine whether the following statement about authorization systems is true or false:
Only physicians can make nonauthorization decisions based on medical necessity.
Home healthcare encompasses a wide variety of medical, social, and support services delivered at the homes of patients who are disabled, chronically ill, or terminally ill. The time period(s) when health plans typically use home healthcare include
1. The period prior to a hospital admission
2. The period following discharge from a hospital
The Midwest Health Plan delegated utilization review (UR) activities to the Tri-City Utilization Review Organization. After Tri-City improperly recommended denial of payment for services to a Midwest plan member, the plan member filed suit. The court ruled that Midwest was responsible for Tri-City’s actions because of the relationship between Midwest and Tri-City. This situation is an illustration of a legal concept known as
