Utilization Review

The utilization and case management team is responsible for monitoring provider and member data to determine appropriateness of services utilized. In addition, the team has established the periodic review criteria for case management of high-risk areas.

The utilization and case management team collects and analyzes data pursuant to quality measurement guidelines. The guidelines include all three areas of utilization management; prospective, concurrent, and retrospective review. These guidelines shall be available to all providers and may be modified as necessary by the utilization and case management team.

Prospective review is a review method of authorizing elective services to assure that the services are necessary and are being provided in the most cost-effective manner. Prospective review is assisted by the use of treatment protocols and practice guidelines developed for chiropractic conditions. Reviews include but are not limited to; elective treatments, therapy, and referrals for consultation outside of the network.

Concurrent review is the ongoing assessment of any additional requests for services beyond the original plan but within the same episode of care. Concurrent review is vital and involves the examination of a patient’s medical record during the time of care to assess the medical necessity and appropriateness of continued care. If, at the time of review, predetermined criteria is not met, the UR/QA Team will discuss the case with the attending provider and the insuring company, as established in the procedures.

Retrospective review is the evaluation of care that has already occurred. This type of review includes evaluation of utilization statistics be it either general or case/physician specified, for educational and quality assurance purposes. This review will be accomplished by but not limited to electronic claims review utilizing ICD-9CM and CPT codes appropriate to the services to develop a provider profile database and the review of outcome management protocol (e.g., clinical, functional, satisfaction-related, and fiscal outcomes).

Regular reports show the individual provider’s practice profile compared to the network’s practice patterns. These reports are freely shared with each provider which enables and encourages the provider to self-monitor efficiency.

The Natural Choice in Healthcare ™

PO Box 220395 Charlotte, NC 28222
704.523.3440 [BUS] 1.877.203.3440 (Toll Free) 704.844.2977 [FAX]