Utilization Review
Pre-Certification or Pre-Authorization Determination is a prospective review of the appropriateness and/or medical necessity of a specific healthcare procedure or treatment.
Peer Review or Claim File Review is a comprehensive file review addressing the chronology of the claim since inception and providing recommendations relative to the future treatment plan, return to work ability, appropriateness of prior treatment and/or extent of injury.
EVIDENCE-BASED CLAIM MANAGEMENT IN UTILIZATION REVIEW: A PROVEN SUCCESS
- Improved outcomes for the injured worker and lower costs for the employer
- Promotes an environment conductive to the well-being of the injured worker
- Based on reliable science
- Proven to improve outcomes while lowering costs
- Your best choice for your injured workers and your bottom line.
UTILIZATION REVIEW PROCESS SUMMARY:
Who makes the Determination: medical necessity approval determinations, or pre-certification, can be made by a licensed healthcare professional, including nurses and/or physicians. Medical necessity adverse or denial determinations must be made by a licensed physician.
What is reviewed: in general terms, a final determination is made regarding a specific healthcare procedure/treatment following a review of supporting medical documentation. This would include, but is not limited to 1-3 clinical evaluation reports, diagnostic or special testing reports, and physical therapy records. A utilization review determination does not involve a comprehensive claim file review and the determination report is generally concise, speaking only to the issue at hand.
Unless mandated by the state Workers' Compensation plan, the pre-certification process covers such items as:
- Inpatient Hospital Admissions/Procedures
- Ambulatory Procedures: outpatient surgery, injections, discography
- Physical or Occupational Therapy
- Durable Medical Equipment
- Diagnostic Testing: MR imaging, Myelography
- Work Hardening/Conditioning Programs
- Chronic Pain Programs
- Psychological Testing and Treatment
- Experimental or Investigational Procedures
BENEFITS OF USING NOVARE PRECERTIFICATION:
- Nurses and Physicians are trained in data-driven care.
- Utilization Review is used as an opportunity to negotiate improved treatment plans and promote return to work.
- Reviewers identify developing problems early and communicate with adjusters.
- The use of voluntary pre-certification promotes data-driven utilization of interventions not requiring pre-authorization.
BENEFITS OF USING NOVARE MEDICAL REVIEW:
- Reviews completed by a data-driven practitioner
- Opinions are supported by scientific data rather than mere conjecture
- Ordered same day as receipt of pre-authorization for:
- Discogram
- Spinal Surgery
- Invasive Therapy for CRPS II
- Bradford Hill/NIOSH Criteria reviews are available for causation or work-relatedness disputes
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