MED-VALUTM

The MED-VALU Management Team The MED-VALU management team consists of Medical directors, regional managers and the owners of MED-VALU. The MED-VALU Management Team establishes and approves all policies and procedures by which MED-VALU performs its utilization review. All activities and deliberations, which in any way involve review or evaluation of the care of services received by an insured or delivered by a provider, are strictly confidential. The responsibilities of the MED-VALU management team are: To monitor, evaluate, and resolve problems and concerns identified by utilization review activities To ensure the confidentiality of all utilization management activities, decisions, and recommendations To evaluate policies and procedures as licensing and accreditation requirements change to ensure compliance To supervise and support the utilization review activities of the nurse reviewer personnel The functions of the MED-VALU management team are: To implement, monitor, review, and evaluate utilization review guidelines and monitoring criteria as they apply to professional and institutional practice and performance. The guidelines and criteria must be objective, measurable, clinically valid, and comparable with established principles of patient care. To collect utilization review data; to identify, track, trend, and analyze trends that data; and on the basis of this review and analyze to recommend appropriate programs and corrective actions and monitor the implementation of the recommended programs and actions To supervise and support the utilization review activities of physician and non-physician personnel To educate providers concerning inappropriate utilization of care or delivery of services identified by findings and analysis generated by utilization review activities To support collection and analysis of data by continuously evaluating the performance of an effective medical information system and the criteria embedded in the system To continuously review the appropriateness and effectiveness of the Utilization Review Plan. Certification of Medical Necessity of Care of Services All decisions substantiating the medical necessity for delivery of care or services are made on the basis of the guidelines and criteria adopted by the MED-VALU Management team. All information required to make a decision for medical necessity will be acquired through the review and certification processes implemented by the MED-VALU Utilization Review Program. The MED-VALU Utilization Review Program includes protocols for pre-admission and pre-procedure review and certification, hospital admission continued stay review and certification, review and certification for delivery of other services, and review of referrals for procedures or other services to participating and non-participating providers. Some protocols are optional services to be contracted for separately. All decisions substantiating and certifying medical necessity for care are subject to appeal by an affected insured, provider, or payer. 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. © Med-Valu, Incorporated