List three purposes for performing quality/utilization management.
What will be an ideal response?
Determining whether services and items were responsible and medically necessary and allowed under the carrier's policy provisions or, in the case of Medicare or Medicaid, allowable under the Conditions of Participation contract.
Reviewing the quality of services rendered with regard to acceptable standards of health care.
Determining whether additional inpatient hospital time is necessary to arrange for post-discharge care.
Determining whether level-of-care criteria have been and continue to be met, thus ensuring continued benefit coverage.
Providing preliminary notification to a practitioner or provider when services or items are found to be unacceptable to health care standards.
Providing an avenue of appeal in the form of a reconsideration hearing, with results provided in notification to the involved parties.
Notifying a patient of continued-stay decisions based on medical need and carrier policy.
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