Utilization Management

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E/F Key Benefits

  • Assists with determinations of compensability and medical necessity

  • Board certified physicians in all specialties

  • Adherence to state guidelines and mandates

  • 24-48 hour TAT for medical necessity review

  • Dedicated RN's available

 



Utilization Management provides a review of procedures and treatments to determine medical necessity and/or work-relatedness. Our registered nurses and physicians utilize nationally recognized protocols, alleviating unnecessary medical costs and assisting our clients in saving valuable claims dollars.

The following components are available:

  • Precertification/Preauthorization — reviewing information prior to inpatient admission, or selected outpatient treatments or services, to determine medical necessity of the proposed treatment or admission.

  • Concurrent Review — determines the medical necessity of continued inpatient admission or treatment.

  • Retrospective Review — determines the medical necessity of care that has already been provided to a claimant.

  • Peer Review — a physician review to determine if a condition or injury is work related; this often assists in determining compensability of a worker’s compensation claim.

  • File Review and Bill Audit — Medical records are reviewed to ensure compliance with the worker’s compensation, liability, or other pertinent billing criteria for each state. The bills are then reviewed for relatedness and to ensure all charges are supported in the medical record.

  • Prescription drugs/pharmacy review — - Review of prescribed medications to determine medical necessity and appropriateness to treat the worker’s compensation claim. - Reviews may also address relatedness to the compensable work injury and provide recommendations for alternative medications/treatment options.


    • Referrals
      Phone (866) 227-5002
      Fax (866) 873-0314



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