Utilization
Review is a formal assessment of the medical necessity and appropriateness
of health care services and treatment plans on a prospective,
concurrent, or retrospective basis. Our utilization management
services are
provided through our M Hayes reviewers as well as our Medical
Director who are experts with treatment protocols / services
and types of
providers.
Pre-Certification
Pre-certification is a utilization review function that certifies
the medical necessity and level of care in advance of outpatient
and inpatient surgeries, hospitalizations, diagnostic testing,
physical therapy, and experimental procedures unless specifically
otherwise directed by the claims payer. The M Hayes reviewer approves
or recommends denial of medical services based on nationally recognized
industry protocols such as the Milliman Care Guidelines as well
as the clinical experience of the reviewer.
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Continued Stay Reviews
A continued stay review is defined as a request by a provider,
facility or hospital for more treatment than was originally authorized.
The Utilization Review Nurse may receive a request for an extension
of days of an inpatient hospitalization or a request for more treatment
than was originally authorized. The Utilization Review Nurse will
compare the reason for the request against established protocols
to assess the appropriateness of the request. Once all the information
is received by the M Hayes reviewer a determination in made within
one business day and the provider is notified also within one business
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Retrospective Reviews
Due to emergencies and other factors there are times when a hospital
admission or procedure can not be pre-certified. In those situations
M Hayes is able to provide a post discharge retrospective review
and can render a professional opinion as to the medical necessity
and appropriateness of treatment. back
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Peer Reviews
Upon receipt of a request for an appeal or reconsideration
M Hayes will arrange for a Peer Reviewer who is Board Certified
or holds
a same or similar specialty of the Authorized Treating Physician.
The formal appeal or reconsideration must be received by M Hayes
within 30 days of the denial. Similarly, the decision of the Peer
Reviewer of the appeal or reconsideration will be made within 30
days of the formal request and the results of the decision will
be communicated within 30 days after receipt of all medical documentation
supporting the appeal or reconsideration request.
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