Utilization Support
Utilization support services focused on appropriate care and effective resource management.
Patient Eligibility / Need / Treatment
- Assessing member eligibility, clinical needs, and treatment plans via medical review subcontracting support to ensure cost-effective care.
Review Phases
- Prior Authorization
Evaluating requested services prior to treatment initiation to ensure clinical appropriateness and authorize initial certifications. - Concurrent Review
Monitoring the clinical status of patients currently undergoing treatment to assess the necessity of continued stay or continued certification. - Retrospective Review
Performing post-service, post-discharge evaluations to verify that care provided met all necessary clinical and billing guidelines.