Question

Source of Information for Assignment:  Florida State Employees PPO Plan Booklet (Effective January 1, 2015): Found in Module. Specifically, students should review "Section 3: Covered Services" and "Section 5: Exclusions".

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 3 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.   

Assignment #3: Utilization Management Scenarios

Scenario #1: Pat Shubert is seeking precertification for coverage of her upcoming breast reconstructive surgery following a mastectomy. The licensed physician has confirmed that the surgery is medically necessary and that the reconstructive surgery will be to re-establish symmetry between the two breasts. Do you approve or deny the claim?

Scenario #2: You have received a claim from an in-network, certified Applied Behavioral Analyst for one of your health plan members, John Smith. John Smith is aged 19 and just graduated from high school. The provider is billing for a visit where John Smith was diagnosed with autism spectrum disorder.   Do you approve or deny the claim?

Scenario #3: You have received a claim from Dr. Addison, an in-network, primary care physician, for a “telephone consultation” with one of your health plan members, Louise Patrick. Do you approve or deny the claim?

Scenario #4:  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 #5: 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?

Answer 1

Scenario 1 - Claim would not be endorsed. PPO does not cover cosmetic services and breast reconstructive medical procedure is barred under this classification of administration.

Scenario 2 - Claim would not be supported. Treatment for Autism Spectrum Disorder is secured for a person under 18 years old or an individual 18 years old or more seasoned who is in high school and who was analyzed as having a Developmental Disability at eight years old or more youthful. For this situation, John Smith does not meet any criteria recorded above and has graduated.

Scenario 3 - Claim ought to be denied as cost/coverage for phone conferences is recorded as avoidance by PPO.

Utilization board is the assessment of the appropriateness, medicinal need, and productivity of human care administration strategies and offices as indicated by built-up criteria or rules and under the arrangement of a pertinent medical advantages plan.

Scenario 4 - Claim ought to be denied as it isn't certified for acupuncture

Scenario 5 - Claim ought to be endorsed in light of the fact that it is certified for acupuncture