Medical Management Concurrent Review
Concurrent review decisions are reviews for the extension of previously approved ongoing care. Examples are the review of in-patient care as it is occurring or ongoing ambulatory care.
Concurrent review provides the opportunity to evaluate the ongoing medical necessity of care being provided, and supports the health care provider in coordinating a member’s care across the continuum of health care services.
- In-patient concurrent review is done telephonically by Medical Management staff.
- All data and relevant information is obtained, including but not limited to medical records, communications with practitioner or other consultants.
- Relevant information is reviewed using utilization management criteria as described in resources/tools section.
- In-patient concurrent review is continuous for the duration of the inpatient stay.
- Urgent concurrent review decisions are made, and the practitioner notified, within 24 hours of receipt of the request. Approval decisions are determined by medical management staff and given to practitioners via oral, electronic, or written notification by facility case managers or discharge planner. Denial decisions are given orally or electronically and in writing to practitioner, facility, and member by medical management staff.
- Concurrent review may include staffing with health care professional and/or home visits with home health care agencies.
- Requests to extend a course of treatment previously approved that does not meet the definition of urgent care will be handled as a new request; for example, pre-service or post-service and the appropriate time frames followed.
- All potential denial decisions based on medical necessity related to concurrent review are reviewed by the Medical Director. A determination is made by him, or in conjunction with consultation of the Associate Director of Behavioral Health.