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Two commonly used UM criteria frameworks are the McKesson InterQual criteria [2] and MCG (previously known as the Milliman Care Guidelines). [3] The guidelines should reflect evidence-based care, although there may be difference between "best practice" and cost-effective acceptable care quality, with payer guidelines emphasizing cost ...
UM criteria are medical guidelines which may be developed in house, acquired from a vendor, or acquired and adapted to suit local conditions. Two commonly used UM criteria frameworks are the McKesson InterQual criteria [23] and MCG (previously known as the Milliman Care Guidelines). [24]
On February 8, 2023, CMS awarded Battelle Memorial Institute a $53 million contract to procure the services of a consensus-based entity, [11] necessary to support various duties pertaining to health care performance measurement, as required under Section 1890 of the Social Security Act. As a result, the National Quality Forum is no longer the ...
A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).
Operating ICFs/IID certified companies and organizations must recognize the developmental, cognitive, social, physical, and behavioral needs of individuals with intellectual disabilities who live in their setting or environment by requiring that each individual receives active treatment in regards to appropriate habilitation of their functions to be eligible for Medicaid funding. [6]
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
The SOI class is meant to provide a basis for evaluating hospital resource use or to establish patient care guidelines. Patients are assigned their SOI based on their specific diagnoses and procedures performed during their medical encounter, which is generally an inpatient hospital stay.
Case management focuses on delivering personalized services to patients to improve their care, and involves four steps: Referral of new patients (perhaps from another service if the client has relocated to a new area out of previous jurisdiction, or if client no longer meets the target of previous service, such as requiring a greater level of ...