Inpatient Prior Authorization and Concurrent Review

Stop paying for unnecessary care and resource consumption.

MedReview’s Inpatient Prior Authorization and Concurrent Review program helps ensure the quality of patient care while reducing unnecessary health claim costs.

Inpatient Prior Authorization

MedReview conducts Prior Authorization for inpatient elective hospital admissions, inpatient psychiatric admissions, skilled nursing facility admissions and acute inpatient rehabilitation facility admissions. Based on URAC/HUM standards, MedReview has 15 calendar days to complete a standard outpatient request and 72 hours for urgent requests. Clinical staff will triage cases and prioritize the review based on the urgency of the patient’s condition.

For this type of review, providers call MedReview to outline the diagnosis, course of treatment, admission date, anticipated length of stay and other relevant clinical information. A clinical decision is made about the medical necessity of the proposed admission and level of care based on nationally recognized guidelines and criteria.

When an admission is approved, providers are informed of the approved days and next review date. Patients, providers and attending physicians are notified of determinations within 24 hours. If an inpatient admission is deemed inappropriate, MedReview will communicate the denial rationale and appeal options will be provided verbally and in writing within 24 hours.

Concurrent Review

MedReview also conducts Concurrent Reviews to evaluate patient care and services during an inpatient stay, validate the necessity of care and explore alternatives to inpatient care. With the goal of ensuring patients continue to receive appropriate care in the right setting while avoiding unnecessary charges, we also track the consumption of resources and the overall progress of patients during their stay.

Data collected during a Concurrent Review includes information about the patient’s continuing health status, his or her current treatment and discharge plan. If the patient has not been discharged yet, the case is reevaluated to determine if medical complications or indications for continuing treatment exist. In the event additional information is needed, we may contact the patient’s attending physician to discuss the patient’s status and care. All information we collect is reviewed against nationally recognized utilization review guidelines and handled in accordance with HIPAA and the HITECH Act.

Inpatient Prior Authorization

MedReview conducts Prior Authorization for inpatient elective hospital admissions, inpatient psychiatric admissions, skilled nursing facility admissions and acute inpatient rehabilitation facility admissions. Based on URAC/HUM standards, MedReview has 15 calendar days to complete a standard outpatient request and 72 hours for urgent requests. Clinical staff will triage cases and prioritize the review based on the urgency of the patient’s condition.

For this type of review, providers call MedReview to outline the diagnosis, course of treatment, admission date, anticipated length of stay and other relevant clinical information. A clinical decision is made about the medical necessity of the proposed admission and level of care based on nationally recognized guidelines and criteria.

When an admission is approved, providers are informed of the approved days and next review date. Patients, providers and attending physicians are notified of determinations within 24 hours. If an inpatient admission is deemed inappropriate, MedReview will communicate the denial rationale and appeal options will be provided verbally and in writing within 24 hours.

Concurrent Review

MedReview also conducts Concurrent Reviews to evaluate patient care and services during an inpatient stay, validate the necessity of care and explore alternatives to inpatient care. With the goal of ensuring patients continue to receive appropriate care in the right setting while avoiding unnecessary charges, we also track the consumption of resources and the overall progress of patients during their stay.

Data collected during a Concurrent Review includes information about the patient’s continuing health status, his or her current treatment and discharge plan. If the patient has not been discharged yet, the case is reevaluated to determine if medical complications or indications for continuing treatment exist. In the event additional information is needed, we may contact the patient’s attending physician to discuss the patient’s status and care. All information we collect is reviewed against nationally recognized utilization review guidelines and handled in accordance with HIPAA and the HITECH Act.

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