Utilization Review/Management » PRIUM Medical Cost Management Services

By: PRIUM  09-12-2011
Keywords: management services, Cost Management, Cost Management Services

Utilization Review/Management » PRIUM Medical Cost Management Services

Prospective Reviews

These clinical reviews are conducted prior to a claimant’s episode of care. (Based on the jurisdiction, they can also be termed Pre-Authorization or Pre-Certification.) They facilitate the proactive management of clinical resources — mandated by either the jurisdiction or the payer — and are used to bring an injured worker back to health and return them to work. This series of reviews addresses a single question of medical necessity, but cannot address causal relatedness. In a non-UM mandated state, a claims person or a nurse case manager can initiate this referral. Otherwise, this referral is initiated by the UM/UR unit. PRIUM follows the 3-level URAC model for all mandated pre-authorizations.

1st Level Review

What are the possible outcomes?

Since a non-physician conducts this review, only three decisions can be made:

Approval. The treatment provider can pursue the requested regimen.

Technical Denial. Regulations were not followed by the treatment provider. Thus the request is denied due to administrative reasons.

Elevate. A peer physician needs to be engaged to look at what the Evidence-Based Medicine cannot approve.

2nd Level Review

What is the purpose?

This is the second step in the UR process. It is only initiated if the 1st Level Review did not either approve or technically deny the treatment request.

What are the possible outcomes?

Several decisions can be rendered by the peer physician:

Approval. The treatment provider can pursue the requested regimen.

Modified with Agreement. The peer physician recommends a modification to the requested treatment regimen and the treatment provider agreed to implement as modified.

Denial. The requested regimen is not approved for clinical reasons (not medically necessary or reasonable).

Reconsideration

What is the purpose?

A reconsideration is utilized if the 2nd level review is unsuccessful in obtaining discussion with the treatment provider or there is additional information made available about the request.

What are the possible outcomes?

Several decisions can be rendered by the peer physician:

Approval. The treatment provider can pursue the requested regimen.

Modified with Agreement. The peer physician recommends a modification to the requested treatment regimen and the treatment provider agrees to implement as modified.

Denial. The requested regimen is not approved for clinical reasons (not medically necessary or reasonable).

3rd Level Review

What is the purpose?

A third-level review is utilized if the second-level review’s decision was a denial, giving the treatment provider one final opportunity to present the rationale behind the treatment request.

What are the possible outcomes?

This decision is final. However, several decisions can be rendered by the peer physician:

Approval. The treatment provider can pursue the requested regimen.

Modified with Agreement. The peer physician recommends a modification to the requested treatment regimen and the treatment provider agrees to implement as modified.

Denial. This requested regimen is not approved for clinical reasons (not medically necessary or reasonable.)

Reviewer. A specialty-matched peer physician (orthopedist to orthopedist, pain management specialist to pain management specialist, etc.).

During the prospective review process, PRIUM manages:

Compliance with the unique requirements for each jurisdiction, including time service.

The Utilization Review Accreditation Committee (URAC) model that is generally accepted as best practices.

Any special requirements from the customer.

Accreditation and licensing of reviewing physicians.

Appropriate assignment per jurisdictional and UM requirements.

Peer Reviews

These clinical reviews are conducted in parallel with treatment of the injured worker and are focused on validating that appropriate care is being rendered according to the nature of the injury and to return the injured worker to health and work as quickly and completely as possible.

What is the purpose?

To work with the treating physician or therapist to develop and agreed-upon treatment plan based upon actual medical necessity.

Retrospective Reviews

What is the purpose?

To form a confidential second opinion and to help guide the claims adjuster or nurse case manager on the most appropriate next steps after treatment has been rendered.

Consultation

What is the purpose?

To provide either a claims adjuster or a nurse case manager direct access, via either e-mail or by phone, to a clinician (MD, DO, DC, etc.) in order to have clinical questions answered or general guidance provided.

Keywords: Clinical Reviews, Cost Management, Cost Management Services, management services, Medical Necessity, Treatment Provider,

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