Prior What?!!?

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Across
  1. 3. Services that help a person with a mental or physical disability maintain or improve skills needed for daily living. These may be subject to different prior authorization rules than other services.
  2. 4. The presence of both a mental health disorder and a substance use disorder in the same person. This can complicate the prior authorization process.
  3. 6. A utilization management protocol that requires a patient to first try a less expensive or preferred medication or treatment before the insurance plan will cover a more expensive or non-preferred alternative.
  4. 9. A mental health condition where the person's use of a substance, like alcohol or drugs, leads to health problems or an inability to meet their work, school, or home responsibilities.
  5. 11. A formal request to an insurance company to reconsider a denied prior authorization request or claim.
  6. 14. A broad term that encompasses both mental health and substance use disorders.
  7. 17. The refusal by an insurance company to cover a specific service.
  8. 18. Standardized letter and number combinations used by healthcare providers to classify and document a patient's diagnosis.
  9. 20. An authorization for a service that has already been provided. This is usually only granted in specific circumstances, such as an emergency.
  10. 21. Mental health care that requires a patient to stay overnight at a hospital or residential facility.
  11. 22. A review process conducted after a patient has been admitted to a higher level of care to determine if continued services are medically necessary.
  12. 24. A group of healthcare providers, hospitals, and clinics that have a contract with an insurance plan to provide services at a discounted rate.
Down
  1. 1. A specific service or condition that is not covered by an insurance plan.
  2. 2. Standardized codes used to describe the medical, surgical, and diagnostic services provided by a healthcare professional.
  3. 5. The standard used by an insurance company to determine if a service or treatment is reasonable, necessary, and appropriate for a patient's condition. This is often based on clinical guidelines and evidence-based practices.
  4. 7. The process of getting pre-approval from a health insurance plan before a patient receives a specific medical service, treatment, or medication. It's also known as preauthorization, precertification, or prior approval.
  5. 8. A set of techniques used by health insurance plans to manage healthcare costs by influencing patient care decisions. Prior authorization is a key component of this.
  6. 10. A written order from a primary care physician to a patient to see a specialist, which is often required by HMO plans.
  7. 12. The first step in the prior authorization process where the insurance company reviews the request to ensure all necessary information has been submitted.
  8. 13. A collaborative process where a professional helps a patient navigate the healthcare system, including accessing services, resources, and coordinating care.
  9. 15. A decision by an insurance company to deny or reduce a requested service or treatment.
  10. 16. The specific, evidence-based guidelines and standards that an insurance company uses to evaluate the medical necessity of a treatment.
  11. 19. Mental health care services that a patient receives without being admitted to a hospital or residential facility, such as individual therapy, group therapy, or medication management.
  12. 23. A healthcare provider or facility that does not have a contract with a patient's insurance plan. Prior authorization for out-of-network services can be more complex and costly.