Med-Valu, Incorporated

MED-VALUTM

The MED-VALU Processes

Preadmission Certification:
The preadmission certification process provides the mechanism to ensure that elective admissions and specific procedures are medically necessary and appropriate, provide cost savings where possible, and identify alternative delivery settings when appropriate. This process is applied to all elective admissions and surgeries. the process can also be applied to a specific list of outpatient procedures and surgeries (see standard list). The outpatient list can be modified to meet the requirements of the payor.
Concurrent Review:
The concurrent review process provides a continuing assessment of the appropriateness of diagnostic studies and therapeutic interventions performed as part of an inpatient admission. It provides the opportunity to encourage medically appropriate discharges of hospitalized patients.

The concurrent review process will include:
1. All emergency admissions and surgeries are authorized and certified within 24 hours of notification of admission.
2. Continued stay review and certification of additional days as medically necessary
3. Identification of appropriate alternative delivery settings and mechanisms.
4. Discharge planning when appropriate.
  The discharge planning process will:
  1. Identify those admissions that will benefit from early discharge intervention,
  2. Identify those admissions that require alternative delivery settings or mechanisms post-discharge,
  3. Facilitate the availability of and transfer to alternative settings of care or services.
Referral for appropriate case management consultation and intervention.
Case Management:
The case management process facilitates the delivery of health care services to patients with severe, complicated, protracted, or chronic illnesses or conditions and to provide appropriate early identification and intervention for those patients. Case management involves aspects of concurrent review and discharge planning but will focus on the most effective use of resources for the seriously or chronically ill. Case management efforts may be either episodic during a specific admission or may be continuous between admissions.
Ambulatory Services Review
The ambulatory service review process assesses the effectiveness and efficiency of care and services delivered in provider’s offices, emergency rooms, urgent care centers, and other outpatient facilities.
1. Provides utilization guidelines and criteria for evaluation of care and services rendered in ambulatory settings;
2. Implements concurrent and retrospective reviews using those guidelines and criteria;
3. Tracks the results of the review;
Medical Director/Physician reviewer
Physician intervention for determination of medical necessity is used when:
1. An elective procedure does not meet established review criteria or guidelines;
2. A continued inpatient stay is no longer considered medically necessary by established criteria and guidelines;
3. There has been failure to pre-certify an elective service or procedure.
In the event a denial for care or services is rendered by the medical director or physician reviewer, notification of that denial, including an explanation of the basis for that denial, will be provided to the insured, the attending physician, and the hospital or clinic as required by existing policies and regulatory requirements.
Appeals Process:
Care or services that have not been authorized by the medical director/Physician reviewer are subject to appeal upon request. There are several levels of appeal available. Please click HERE for more detailed information of the appeals process.
Guidelines and/or Criteria:
MED-VALU has adopted guidelines and criteria from Milliman and Robertson. The guidelines and criteria are used for screening for utilization review activities and are not meant to constitute standards of care. Rather, they provide indications of appropriateness and signal when the use of peer medical reviewer may be required.