Utilization Management Review Test

17 Questions | Total Attempts: 202

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Management Quizzes & Trivia

Test your knowledge on material read for Utilization Management information.


Questions and Answers
  • 1. 
    Medicare came into existence in 1965 as an amendment to the Social Security Act .
    • A. 

      True

    • B. 

      False

  • 2. 
     The primary responsibilities of the UM/UR Nurse include which of the following…
    • A. 

      Enforcing DRG rules

    • B. 

      Evaluate medical necessity

    • C. 

      Evaluate appropriatenss of care

    • D. 

      Both B & C

  • 3. 
     Mr. H. was referred by his PCP to an Orthopedic Surgeon for evaluation of worsening right hip pain. The surgeon has recommended a right total arthroplasty.  What type of review will be performed prior to approval of this procedure?
    • A. 

      Admission

    • B. 

      Preadmission

    • C. 

      Concurrent

    • D. 

      Contiued Stay

  • 4. 
    UM is effective only in an enviornment of complete objectivity which is enhanced by the use of accepted severity of illness and intensity of service criteria.
    • A. 

      True

    • B. 

      False

  • 5. 
    When counting the days for length of stay it is important to remember not to count:
    • A. 

      Day of admission

    • B. 

      Day of discharge

    • C. 

      Day of admission and day of discharge

    • D. 

      Count all days including admission and discharge days

  • 6. 
    The goal of WellMed's UM department is to ensure the delivery of the services in a quality oriented, timely, medcally appropriate, and the cost efficient manner for the health plan's membership.
    • A. 

      True

    • B. 

      False

  • 7. 
    The UM Nurse will base their decision on:
    • A. 

      Their opinion of need

    • B. 

      Standardized objective criteria

    • C. 

      The cost involved

    • D. 

      All of the above

  • 8. 
    Everyone over the age of 65 are automatically eligible for Medicare.
    • A. 

      True

    • B. 

      False

  • 9. 
    All members if Medicare Advantage Plans receive coverage at least equal to that of traditional Medicare.
    • A. 

      True

    • B. 

      False

  • 10. 
    After meeting the Medicare Part B deductible, the patient is responsible for how much of the remaining bill?
    • A. 

      10%

    • B. 

      20%

    • C. 

      25%

    • D. 

      0%

  • 11. 
    CMS depends on hospitals to monitor the challenge of controlling readmissions.
    • A. 

      True

    • B. 

      False

  • 12. 
    Provides a comprehensive set of health benefits on a prepaid basis directly to its enrollees through designated physicans and hospitals.
    • A. 

      Preferred Provider Organization (PPO)

    • B. 

      Health Maintenance Organization (HMO)

    • C. 

      Point of Service Plans (POS)

    • D. 

      Traditional Indemnity Plan (TIP)

  • 13. 
    This organization's role is to regulate and supervise HMO's
    • A. 

      Utilization Review Accreditation Commission

    • B. 

      Centers for Medicare & Medicaid Servies

    • C. 

      National Committee for Quality Assurance

    • D. 

      Department of Affordable Health

  • 14. 
    If a request for service is denied it is the responsibility of the UM/UR nurse to inform the patient and the requesting physician of their right to appeal.
    • A. 

      True

    • B. 

      False

  • 15. 
    Nurse Reviewers play a major role in assuring the effective use of healthcare dollars in America.
    • A. 

      True

    • B. 

      False