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Concurrent Review Certification Call The First Level Clinical Reviewer (Registered Nurse), will call either the attending physician or the facility to obtain clinical information to review the case. This call is placed on the last certified day or the first uncertified day of the ongoing medical service. The tickler feature of the Med-Valu software identifies all cases requiring concurrent review on a specific day. If the medical information needed to complete and certify an extension of the medical service based on medical necessity criteria or the First Level Reviewer's (Registered Nurse) medical judgment, the MED-VALU Nurse will notify the attending physician that an extension has been certified. If, based on medical necessity criteria, the MED-VALU nurse is unable to certify the an extension of service, he/she will forward the case to Med-Valu’s Medical Director, on the same business day, for a Peer-to-Peer Review by a Second Level Reviewer (Licensed Physician). Upon receipt of a case for review, the Peer Reviewer will contact the attending physician on the same business day. If the attending physician supplies information necessary to certify an extension of service the Peer Reviewer will notify the attending physician that an extension has been certified at the time of the call. Notice of certification is also returned to the Med-Valu Medical Director and Med-Valu nurse. The Med-Valu nurse updates the case record. If the Peer Reviewer, when speaking to the attending physician, is unable to certify an extension of the medical service based on the medical necessity criteria and his/her medical judgment, he/she will notify the physician's office of the non-certification decision at that time. The Peer Reviewer will also inform the physician's office that they have the right to appeal the decision and have the request for the specified medical service reviewed by yet another Peer Reviewer who is licensed in the same or similar specialty that typically provides the requested service. Should the attending physician decline to appeal, the Peer Reviewer will, on the same business day, notify the MED-VALU Medical Director and the First Level Reviewer of the decision not to certify the requested medical service. |
