MANAGED CARE EXAM 3 (2025) 139
QUESTIONS WITH ALL SOLVED SOLUTIONS!!
What does prevention target do? - ANSWER: Preventing certain
diseases or conditions
&*)_++
_((*&^
#@!!@
What is the most common form of prevention? - ANSWER: Childhood #$#@~
!@$%
Immunizations
&&%$
%%^
What types of programs or services are targeted by wellness
programs? - ANSWER: Helping member to change their lifestyles
and develop healthy habits
What are HRAs? - ANSWER: Self-administered assessment tool
used to quickly make an overall assessment of new patient's medical
condition and risk factors
What is the common measurement of inpatient utilization? -
ANSWER: Utilization per thousand (bed days per thousand)
What is the difference between coverage decisions and medical care
decision? - ANSWER: Medical care decisions are made by a doctor
and a patient. Coverage decisions are made by managed healthcare
plans.
, MANAGED CARE EXAM 3 (2025) 139
QUESTIONS WITH ALL SOLVED SOLUTIONS!!
Prospective utilization management - ANSWER: o Demand
management
&*)_++
o Referral management _((*&^
#@!!@
o Precertification of costly services #$#@~
!@$%
&&%$
%%^
Concurrent utilization management - ANSWER: o UM activities
performed while care is being provided
o Primarily used for hospital inpatient care, long-term outpatient care,
and costly care
Discharge planning - ANSWER: o A function of concurrent UM
o Can also be an important element of case management
o Involves working with hospital's discharge planning department to
facilitate discharge by arranging follow-up services
Medical necessity - ANSWER: o A factor in coverage determination
when medical goods or services may or may not be covered depending
on certain criteria
o Applied to benefits coverage policies and determinations is often
difficult for members and providers to understand
, MANAGED CARE EXAM 3 (2025) 139
QUESTIONS WITH ALL SOLVED SOLUTIONS!!
Evidenced-based clinical criteria and guidelines are based on... -
ANSWER: formal medical studies and clinical trials
&*)_++
_((*&^
#@!!@
Basic utilization management: - ANSWER: refers to routine #$#@~
!@$%
functions used to manage the cost of the most widely used medical
&&%$
services %%^
Formulary - ANSWER: A list of drugs covering typical medical needs,
but it does not include all available drugs for each medical condition
Tiering strategies - ANSWER: categorize coverage into different
tiers, or benefits level
Peer review - ANSWER: Consists of internal information gathering
specific to a provider and relevant to the identified potential issues,
review by a plan medical director, and peer review by a physician
committee
Health plan accreditation - ANSWER: A form of oversight in which
an independent, private, nonprofit organization reviews an MCO and
determines if it meets certain criteria or industry standards
, MANAGED CARE EXAM 3 (2025) 139
QUESTIONS WITH ALL SOLVED SOLUTIONS!!
Payer and MCOs Accreditation - ANSWER: o National Committee of
Quality Assurance (NCQA)
&*)_++
o URAC (Utilization Review Accreditation Commission) _((*&^
#@!!@
o Accreditation Association for Ambulatory Health Care (AAAHC) #$#@~
!@$%
&&%$
%%^
HEDIS - ANSWER: An industry standard for reporting data to
employers and many government agencies; it allows true 'apples to
apples' comparison
Retrospective Utilization Management - ANSWER: o UM or UM
related activities that take place after care has been provided
o Case review and pattern analysis
Case Management - ANSWER: o Trained nurse coordinate aspects of
care such as rehabilitation, home care, health education
o Improve outcomes and reduce expenses
Disease Management - ANSWER: o A form of CM
o Focused on a handful of selected conditions and works proactivity
with each patient to manage the course of the disease an avoid the
need for hospitalization
QUESTIONS WITH ALL SOLVED SOLUTIONS!!
What does prevention target do? - ANSWER: Preventing certain
diseases or conditions
&*)_++
_((*&^
#@!!@
What is the most common form of prevention? - ANSWER: Childhood #$#@~
!@$%
Immunizations
&&%$
%%^
What types of programs or services are targeted by wellness
programs? - ANSWER: Helping member to change their lifestyles
and develop healthy habits
What are HRAs? - ANSWER: Self-administered assessment tool
used to quickly make an overall assessment of new patient's medical
condition and risk factors
What is the common measurement of inpatient utilization? -
ANSWER: Utilization per thousand (bed days per thousand)
What is the difference between coverage decisions and medical care
decision? - ANSWER: Medical care decisions are made by a doctor
and a patient. Coverage decisions are made by managed healthcare
plans.
, MANAGED CARE EXAM 3 (2025) 139
QUESTIONS WITH ALL SOLVED SOLUTIONS!!
Prospective utilization management - ANSWER: o Demand
management
&*)_++
o Referral management _((*&^
#@!!@
o Precertification of costly services #$#@~
!@$%
&&%$
%%^
Concurrent utilization management - ANSWER: o UM activities
performed while care is being provided
o Primarily used for hospital inpatient care, long-term outpatient care,
and costly care
Discharge planning - ANSWER: o A function of concurrent UM
o Can also be an important element of case management
o Involves working with hospital's discharge planning department to
facilitate discharge by arranging follow-up services
Medical necessity - ANSWER: o A factor in coverage determination
when medical goods or services may or may not be covered depending
on certain criteria
o Applied to benefits coverage policies and determinations is often
difficult for members and providers to understand
, MANAGED CARE EXAM 3 (2025) 139
QUESTIONS WITH ALL SOLVED SOLUTIONS!!
Evidenced-based clinical criteria and guidelines are based on... -
ANSWER: formal medical studies and clinical trials
&*)_++
_((*&^
#@!!@
Basic utilization management: - ANSWER: refers to routine #$#@~
!@$%
functions used to manage the cost of the most widely used medical
&&%$
services %%^
Formulary - ANSWER: A list of drugs covering typical medical needs,
but it does not include all available drugs for each medical condition
Tiering strategies - ANSWER: categorize coverage into different
tiers, or benefits level
Peer review - ANSWER: Consists of internal information gathering
specific to a provider and relevant to the identified potential issues,
review by a plan medical director, and peer review by a physician
committee
Health plan accreditation - ANSWER: A form of oversight in which
an independent, private, nonprofit organization reviews an MCO and
determines if it meets certain criteria or industry standards
, MANAGED CARE EXAM 3 (2025) 139
QUESTIONS WITH ALL SOLVED SOLUTIONS!!
Payer and MCOs Accreditation - ANSWER: o National Committee of
Quality Assurance (NCQA)
&*)_++
o URAC (Utilization Review Accreditation Commission) _((*&^
#@!!@
o Accreditation Association for Ambulatory Health Care (AAAHC) #$#@~
!@$%
&&%$
%%^
HEDIS - ANSWER: An industry standard for reporting data to
employers and many government agencies; it allows true 'apples to
apples' comparison
Retrospective Utilization Management - ANSWER: o UM or UM
related activities that take place after care has been provided
o Case review and pattern analysis
Case Management - ANSWER: o Trained nurse coordinate aspects of
care such as rehabilitation, home care, health education
o Improve outcomes and reduce expenses
Disease Management - ANSWER: o A form of CM
o Focused on a handful of selected conditions and works proactivity
with each patient to manage the course of the disease an avoid the
need for hospitalization
