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Utilization Management

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.

  • Clinical assessment
  • Diagnostics
  • Early Intervention
  • Light / Modified Duty Coordination
  • Length of Disability based on established standards
  • Return to Work Coordination
  • IME Coordination
  • Field Case Management Coordination
  • PPO Channeling
  • Facilitation of Utilization Management
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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.

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 day.

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.

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.

Privacy Policy

M Hayes recognizes the importance of keeping your personal information private in the online environment. It is our policy that any personal information provided by a user will never be sold, rented or shared with any third party or any person or organization not directly involved with M Hayes’ business.

Information on the website is gathered through tracking of general online website statistics; for example, the number of visitors to our site, the pages viewed and the files accessed. While certain features of the site may employ "cookies" to better facilitate services, at no time is any personal or specific information about the visitor collected, except in circumstances where the visitor knowingly shares such information, such as through completion and submission of an online Referral form or an e-mail from the visitor to M Hayes.

Our privacy policy does not apply to third party websites that you link to or reach through our website. You should read the privacy policies of those third parties to learn how they collect and use information about you.