Introduction to the Medicare Hierarchy

Activity description

When reviewing service requests for members with a Medicare Advantage (MA) plan, it is a requirement to follow the appropriate Medicare Hierarchy for either an Inpatient or Prior Authorization request. The review process requires navigating to health plan criteria, CMS guidelines, and external criteria. This activity will highlight the Medicare Hierarchy and resources utilized to ensure that the requested items and services are medically necessary.

Course last reviewed: 2/4/2022

Provided by
This activity is provided by OptumHealth Education and Optum Care.

Commercial support
No commercial support was received for this activity.

Hardware/Software Requirements
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Target Audience

This activity is designed to meet the educational needs of case managers, nurses, pharmacists, pharmacy technicians and physicians interested in medical review criteria.

Learning Objectives

At the end of this educational activity, participants should be able to:

  • Identify the appropriate resources needed to follow the Medicare Hierarchy of Review.
  • Utilize resources appropriately to comply with Applying Medicare Plan and Review Criteria Standard Operating Procedure (SOP).
  • Compare the differences in the hierarchy of review for both Inpatient and Prior Authorization requests.
Activity summary
Available credit: 
  • 1.00 ACPE - Pharmacists
  • 1.00 ACPE - Pharmacy Technicians
  • 1.00 AMA - Physicians
  • 1.00 ANCC - Nurses
  • 1.00 Attendance - General Attendance
  • 1.00 CCMC - General - Case Managers
Activity opens: 
06/28/2021
Activity expires: 
06/28/2024

Faculty/Planners
Sarah Chart, RN
Vice President
OptumHealth Education

Rebecca Gleason, RN, CCM
Clinical Planner
OptumHealth Education

Lolly Bilous, MSN, RN, CCM
Training Consultant 
Clinical Adherence and Remediation
Clinical Consistency and Safety
Clinical Performance
Optum Care

Lewis Gregory, MD, MBA
National Medical Director
Clinical Affordability
OptumCare

Valerie Ventura, MSN, RN
Vice President
Clinical Adherence and Remediation
Clinical Consistency and Safety
Clinical Performance 
Optum Care

Tiffany Younts, MSN, RNC-OB, CCM
Training Consultant 
Clinical Adherence and Remediation
Clinical Consistency and Safety
Clinical Performance
Optum Care

Disclosures of relevant financial relationships
In accordance with the Accreditation Council for Continuing Medical Education's (ACCME) Standards for Integrity and Independence in Accredited Continuing Education, OptumHealth Education (OHE) requires all those in control of educational content to disclose their financial relationships with ineligible companies within the prior 24 months. Ineligible companies are defined by the ACCME as companies whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients. Individuals must disclose all financial relationships, regardless of the amount, with ineligible companies and regardless of their view of the relevance of the relationship to the education. OHE ensures that the content is independent of commercial bias.

The activity faculty or planners have no financial relationships to disclose.

Method for calculating CE credit
CE credit was calculated by the complexity of content.

Accreditation Statement
Joint LogoIn support of improving patient care, this activity has been planned and implemented by OptumHealth Education and Optum Care. OptumHealth Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team.

Credit Designation Statements

Nurses
The participant will be awarded up to 1.00 contact hours of credit for attendance and completion of supplemental materials.

Nurse practitioners
The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.

Pharmacists/Pharmacy technicians
This activity is approved for 1.00 contact hour ([0.10] CEU) in states that recognize ACPE.
Attending the full program will earn 1.00 contact hour.
Unique Activity Number(s): JA0007123-9999-21-105-H04-P/T

Physicians
OptumHealth Education designates this enduring activity for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

PAs
The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME.

Case managers
The Commission for Case Manager Certification has approved this program for a maximum of 1.00 clock hours for Certified Case Managers (CCM).

Attendance
A certificate of attendance will be provided to learners upon completion of activity requirements, enabling participants to register with licensing boards or associations that have not been pre-approved for credits. To apply for credit types not listed above, participants should use the procedure established by the specific organization with which they wish to obtain credit.

Available Credit

  • 1.00 ACPE - Pharmacists
  • 1.00 ACPE - Pharmacy Technicians
  • 1.00 AMA - Physicians
  • 1.00 ANCC - Nurses
  • 1.00 Attendance - General Attendance
  • 1.00 CCMC - General - Case Managers
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