Utilization Management

utilization management reviews care coordinatorsProviding specialty-matched peer review services, NMR supports the healthcare claim process by determining the medical necessity and reasonableness of healthcare services and/or procedures according to established criteria or guidelines at all levels of reviews.

Review Levels:

1. First Level Review – A nurse level professional typically conducts the Initial Clinical Review with clinical support from a Medical Director who most often is a physician.
a.) Initial Determination – Adverse Benefit Determinations are rendered by Medical Director level professionals.

2. Second Level Review – This level of review includes an internal appeal process giving consumers the right to have their denied claim reviewed by a clinical professional in the same or similar specialty of the treating provider.
a.) All jurisdictions allow for at least one level of internal appeal.
b.) Various jurisdictions allow for a second level internal appeal.

3. Third Level Review – Once the internal appeal process has been exhausted, consumers have the right to have their denied claim reviewed by an Independent Review Organization.

Internal Claim Reviews

National Medical Reviews (NMR) is an URAC Accredited Internal Independent Review Organization

First Level Review – NMR provides Medical Director Services to assist Plans in the adjudication of new claims. Our clinical specialists are located throughout the United States and encompass all specialties and sub-specialties.

Second Level Review – At the appeal level, NMR provides Specialty Matched Peer Review Services meeting all regulatory requirements for the specific claim under review.

Services Provided:
• Brief Report
– Answer to the specific question(s) to be addressed
– Provide references to support answer
– Summary of Claim History
– Specific reference to where the clinical information met/does not meet the plan language/guidelines that governs the claim under review
• Medical Director-to-Medical Director consultations
• Member Hearings
• Peer-to-Peer Contact (if required)

Major Topics Addressed:
• Administrative/Contract Reviews
• Behavioral Health Reviews (Adult, Child & Adolescent, Addiction, Forensic)
• Experimental/Investigational
• Health Benefit Coverage Disputes
• Hospital Accounting/Claims/DRG Reviews
• Hospital Admissions & Length of Stay
• Medical Necessity/Reasonableness
• Medical/Surgical Reviews
• Prescription Reviews
• Rescission Reviews
• Skilled Nursing Facility/RUG Appeals

Independent External Reviews

State Mandated External Review (Third Level Review)
• A State legislated process that affords consumers the right to request an independent review of an adverse benefit determination
• NMR provides these services either by contract or certification for multiple state agencies throughout the United States

Federal External Review Process (Third Level Review)
• As an URAC Accredited External Independent Review Organization, NMR is compliant to provide this service as mandated in the Affordable Care Act (ACA).
• NMR contracts with self funded employer and multi-employer groups to act as the IRO to conduct an independent external review as provided in the ACA.

Alternate Dispute Resolution
• A contractual agreement between a plan and healthcare facility(ies) to have claim disputes resolved by an Independent Review Organization (IRO).
• Typically, both parties are bound by the IRO’s determination.
• Typically the losing party is responsible for payment of the IRO’s services

Services Provided:
• Aggregate Reporting to appropriate parties as required
• Collection and dissemination of additional information as required
• Full Narrative Report
– Answer to the specific question(s) to be addressed
– Listing of Documents Reviewed (if required)
– Provide references to support answer
– Specific reference to where the clinical information met/does not meet the plan language/guidelines that governs the claim under review
– Summary of Claim History
• Notifications to all parties as required

Major Topics Addressed:
• Administrative/Contract Reviews
• Behavioral Health Reviews (Adult, Child & Adolescent, Addiction, Forensic)
• Experimental/Investigational
• Health Benefit Coverage Disputes
• Hospital Admissions & Length of Stay
• Hospital Accounting/Claims/DRG Reviews
• Medical Necessity/Reasonableness
• Medical/Surgical Reviews
• Prescription Reviews
• Rescission Reviews
• Skilled Nursing Facility/RUG Appeals

Request Information

We offer Utilization Management (UM) internal and external reviews in standard and expedited time frames.

If you would like to learn how NMR’s services can benefit your company, please click the button below:

Request Information from national medical reviews