Across
- 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.
- 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.
- 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.
- 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.
- 11. A formal request to an insurance company to reconsider a denied prior authorization request or claim.
- 14. A broad term that encompasses both mental health and substance use disorders.
- 17. The refusal by an insurance company to cover a specific service.
- 18. Standardized letter and number combinations used by healthcare providers to classify and document a patient's diagnosis.
- 20. An authorization for a service that has already been provided. This is usually only granted in specific circumstances, such as an emergency.
- 21. Mental health care that requires a patient to stay overnight at a hospital or residential facility.
- 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.
- 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. A specific service or condition that is not covered by an insurance plan.
- 2. Standardized codes used to describe the medical, surgical, and diagnostic services provided by a healthcare professional.
- 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.
- 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.
- 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.
- 10. A written order from a primary care physician to a patient to see a specialist, which is often required by HMO plans.
- 12. The first step in the prior authorization process where the insurance company reviews the request to ensure all necessary information has been submitted.
- 13. A collaborative process where a professional helps a patient navigate the healthcare system, including accessing services, resources, and coordinating care.
- 15. A decision by an insurance company to deny or reduce a requested service or treatment.
- 16. The specific, evidence-based guidelines and standards that an insurance company uses to evaluate the medical necessity of a treatment.
- 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.
- 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.