Utilization Review
Utilization Review

Utilization Review, a telephone-based care-management program operated by HealthComp, includes medical necessity reviews by both doctors and nurses. These reviews help to determine that appropriate care for the medical condition is received.

While the purpose of the program is to determine the medical necessity of services, it is not designed to be the practice of medicine or to be a substitute for the medical judgment of the attending physician or other healthcare providers.

If a particular course of treatment or medical service is not certified, the Plan will not consider that course of treatment as appropriate for the maximum reimbursement under the Plan.

HealthComp's Utilization Review includes:

  • Issuing pre-certification based on medical necessity for all inpatient hospitalizations, outpatient surgeries, elective procedures, imaging, diagnostics, outpatient therapies, and durable medical equipment before services are provided

  • Facilitating referrals to Network Providers

  • Concurrent Review

  • Discharge Planning

  • Retrospective Review

  • Physician Advisor Program

  • Appeals Process

  • Identification of patients requiring case management

  • Notification of potential high dollar/complicated cases

  • Price Negotiation with out-of-network providers

  • Direct Contracting

  • Post Claims review

  • Drug prior authorizations for Pharmacy Benefit Manager