Chapter 5

3. _______ utilization management refers to UM activities performed while care is being provided
5. _______ utilization management refers to UM or UM-related activities that take place after care has been provided
7. _______ health care spans both the management of utilization and quality
10. _______ management is a form of case management that focuses on a handful of selected conditions
12. Health plan _______ is a forma of oversight in which an independent, private, nonprofit organization reviews an MCO and determines if it meet certain criteria or industry standards
13. A list of drugs covering typical medical needs, although it does not include all available drugs for each medical condition
14. necessity A factor in coverage determinations when medical goods or services may or may not be covered depending on certain criteria
15. A function of concurrent UM, but it can also be an important element of case management

1. Childhood immunizations are the most common form of _______
2. Self-administered assessment tool used to quickly make an overall assessment of a new patient’s medical condition and risk factors
4. What types of medications do specialty pharmacies include?
6. _______ -based clinical criteria and guidelines are based on formal medical studies and clinical trials that compare different approaches to care
8. _______ is an initiative of the federal AHRQ that seeks to support the assessment of consumers’ experiences with healthcare
9. Basic utilization management refers to the routine functions used to manage the cost of the most widely used _______
11. Payers quality management programs are _______