Review for medical necessity of tests/procedures ordered during inpatient hospitalization.

Elisia GarzaOST 136January 25, 2017Questions for ReviewSELECT THE BEST ANSWER1.The intent of managed health care was to

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2.Which term best describes those who receive managed health care plan services?

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3.The Medical Center received a $100,000 capitation payment in January to cover thehealth care costs of 150 managed care enrollees. By the following January, $80,000 hadbeen expended to cover services provided. The remaining $20,000 is

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4.A nonprofit organization that contracts with and acquires the clinical and business assetsof physician practices is called a

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5.A __ is responsible for supervising and coordinating health care services for enrollees.

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6.The term that describes requirements created by accreditation organizations is

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7.Arranging appropriate healthcare services for discharged patients.

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8.Review for medical necessity of inpatient care prior to admission.

Cigna defines Medical Necessity in the following four ways:

• Medical Necessity for Physicians
• Medical Necessity for other Health Care Providers
• Health Care for Seniors Definition of Medical Necessity for Physicians
• Health Care for Seniors Definition of Medical Necessity for other Health Care Providers

Full descriptions of each are given below.

Cigna's Definition of Medical Necessity for Physicians

"Medically Necessary" or "Medical Necessity" means health care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be:

1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
2. In accordance with the generally accepted standards of medical practice
3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease

For these purposes, "generally accepted standards of medical practice" means:

1. Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community
2. Physician Specialty Society recommendations
3. The views of physicians practicing in the relevant clinical area
4. Any other relevant factors

Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Cigna's Seniors Definition of Medical Necessity for other Health Care Providers

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" refers to health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
2. In accordance with the generally accepted standards of medical practice
3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease

For these purposes, "generally accepted standards of medical practice" means:

1. Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community
2. Physician and Health Care Provider Specialty Society recommendations
3. The views of physicians and health care providers practicing in relevant clinical areas
4. Any other relevant factors

Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Cigna's Seniors Definition of Medical Necessity for Physicians

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" refers to health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
2. In accordance with the generally accepted standards of medical practice
3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease

For these purposes, "generally accepted standards of medical practice" means:

1. Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community
2. Physician Specialty Society recommendations
3. The views of physicians practicing in the relevant clinical area
4. Any other relevant factors

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Cigna's Seniors Definition of Medical Necessity for other Health Care Providers

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" shall mean health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
2. In accordance with the generally accepted standards of medical practice
3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers

For these purposes, "generally accepted standards of medical practice" means:

1. Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community
2. Physician and Health Care Provider Specialty Society recommendations
3. The views of physicians and health care providers practicing in relevant clinical areas
4. Any other relevant factors

Preventive care may be Medically Necessary but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Medical Necessity Criteria for Treatment of Mental Health and Substance Use Disorders

Cigna believes that all treatment decisions that are made in alignment with the Medical Necessity Criteria must be first and foremost clinically based. Care must be patient-centered and take into account the individuals’ needs, clinical and environmental factors, and personal values.

Learn more about our Behavioral Health Guidelines.

Which is a review for medical necessity of tests and procedures?

Which of these is a review of the appropriateness and necessity of care provided to patients prior to the administration of care?

Which type of claim includes those that were rejected due to an error?

Which of these is supporting documentation or information associated with a health care claim or patient encounter?