Utilization Review

Novare LLC is a nationally based Utilization Review Agency focused on helping our clients manage medical aspects of their claims in conjunction with ensuring injured workers are provided with timely and appropriate medical care. Overutilization of medical treatment is a driving factor in the overall cost of a Workers’ Compensation claim. Novare LLC, through the use of licensed nurses, board certified physicians and application of data driven evidence-based guidelines, can help you with those costs by proactive rather than reactive management of medical treatment.

Novare LLC offers national utilization review services including prospective, concurrent and retrospective reviews. Novare offers simple electronic or fax submission of requests for medical necessity. After the initiation of a review and throughout the process, Novare staff communicates with the adjuster to ensure we have the most complete claim and medical history possible to ensure the most appropriate determination of medical necessity is made. Novare LLC provides absolute transparency of our product by providing access to our electronic system to our Clients to track or monitor their utilization review submissions.

Pre Certification/Pre Authorization:
Pre-certification is a proactive tool that can be used in the medical management of a workers’ compensation claim. This review provides an evidence-based opinion of medical necessity for a proposed treatment based on submitted medical documentation and evidence-based treatment guidelines.

Retrospective Review:
Retrospective review is a review of medical necessity performed after the service has been provided. As with pre-certification, this review provides an evidence-based opinion of medical necessity for a proposed treatment based on submitted medical documentation and evidence-based treatment guidelines.

Physician Peer Review:
Physician peer review is an evidence-based review performed by an appropriately licensed medical professional to determine medical necessity of a proposed treatment or treatment that has already been provided.

Drug Utilization Review:
Drug Utilization Reviews are excellent tools to assist the adjuster in addressing claim pharmaceutical usage. These reviews are conducted by a licensed pharmacist who addresses the appropriateness of an injured workers drug regime. This review offers medical evidence to support the use of medications or the lack of evidence to support the continued use of mediation. The review can also provide a recommended drug detoxification program when appropriate.

Early Compensability Review:
An Early Compensability Review is a tool available to the claims adjudicator to address if there is evidence of an injury and, if so, the extent of the injury as supported by the medical documentation. This allows for an assessment of compensability in the early stages of the claim as well as an anticipated medical treatment plan before unnecessary medical expenses are incurred.

Independent Medical Exams:
Independent Medical Exams are examinations of an injured worker by a doctor that that has not been previously involved in the claim. An opinion is provided based on review of the medical documentation and a physical examination of the patient. The doctor addresses questions as posed by the requesting party.

CA UR Plan (PDF)