Utilization Review

Managed care plans balance the need to provide plan members with access to good care, while at the same time utilizing different methods in an effort to control healthcare costs.

Utilization Review is one of these cost saving methods that most health plans rely on to help them manage and monitor the care that patients receive by directing patients to the appropriate levels of care. Depending on what care is needed, the Utilization Review Department (UR) will be the point of contact for all utilization review related inquiries.

The most common levels of Utilization Review are:

Prior Authorization – Prior authorization is the process of obtaining "permission," in advance, to have needed medical services performed. For example, a plan may require that prior authorization be obtained for all CT Scans. The patient's doctor would be required to contact the UR Department to request authorization and to provide the medical necessity to support the needed service.

The UR Department will provide the written authorization based on this need. Failure to obtain a needed authorization, prior to the visit, could result in nonpayment of the claim.

Pre-Certification - Pre-certification is the process of obtaining "permission," for a patient to be admitted to the hospital. Some carriers also require pre-certification for certain out-patient surgical procedures and outpatient hospital stays.

The back of the patient’s ID card will provide the telephone number of where to call in the event that pre-certification is needed. The doctor, the hospital or even the patient or his family can call to start the pre-certification process. Do keep in mind, the patient, or his family, may not be able to complete the process as they may lack the required medical information such as: diagnoses, appropriate codes, anticipated length of stay, etc.

Normally, pre certification is handled in advance, but in the case of emergencies you may have a reasonable amount of time, up to 24 to 36 hours, in which to pre-certify. Failure to pre-certify could result in the reduction or denial of benefits.

Pre-determination- Pre-determination is the process of requesting prior approval for a proposed surgery or service. A pre-determination letter is basically a letter that details the type of service, approximate costs, attending physician, hospital information, patient history, any supporting test results and/or clinical information that will support the medical necessity for the needed surgery or service.

It is good idea to request pre-determination for cases where a very expensive, unique or specialty service/surgery is to be performed. This is a way to find out, in advance, if the procedure would be covered under the plan. Pre-determination normally takes about 30 days for a final decision to be rendered.

Concurrent Review- Concurrent Review is a request for care at the same time that treatment is being rendered. For example, a patient that is hospital confined for a long period of time may be followed by the UR Department, every week or so, just to monitor the care and/or suggests ways to cut cost, etc.

Retrospective Review- A request for care after the service is rendered.


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