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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: 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 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 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 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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