Instructions: For each scenario, you will determine whether the service(s) will
ID: 139471 • Letter: I
Question
Instructions: For each scenario, you will determine whether the service(s) will be covered based on coverage provisions in the member booklet. Indicate whether the service(s) or provider claim is approved or denied. Each scenario should be straightforward as whether to approve or deny, and is worth 5 points.
Note: In "real-life" the scenarios are not so straightforward, and usually require a clinical opinion on whether the service is truly medically necessary and often whether the setting is appropriate. Insurance plan clinicians (e.g. UM nurses and UM medical directors), often review evidence-based medicine to make these decisions and may consult with the patient's "prescribing" physician.
Utilization Management Scenarios
Scenario #1: Marc Jones received acupuncture treatment for migraine headaches at his chiropractor’s office. The chiropractor is in-network but is not certified for acupuncture. Do you approve or deny the claim?
Scenario #2: Betty Smith received acupuncture treatment for migraine headaches at her chiropractor’s office. The chiropractor is in-network and is certified for acupuncture. Do you approve or deny the claim?
Explanation / Answer
Utilization management is the evaluation of the appropriatness, medical need and efficiency of health care service procedures and facilities according to established criteria or guidelines and under the provision of an applicable health benefits plan.
Scenario 1 claim should be deny as it is not certified for accupuncture
Scenario2 should be approved because it is certified for accupucture