|
|
|
Initial review certification call All pertinent data is collected from the caller and entered into the MED-VALU Utilization Review Computer System. If the caller is not the attending physician's office, the attending physician's office is contacted the same day the call is received. All requests for prospective certifications left on voice mail after business hours will be returned the next business day. If the attending physician's office provides the medical information needed to complete and certify the requested medical service based on the medical necessity criteria or the First Level Reviewer's (Registered Nurse) medical judgment, the MED-VALU Nurse will notify the attending physician that the request has been certified. When clinical information does not meet medical necessity criteria the MED-VALU nurse is unable to certify the requested medical service at that time. He/she will forward the case, on the same business day, to MED-VALU's Medical Director for a Peer-to-Peer Review by Second Level Reviewer (Licensed Physician). Upon receipt of a case for review the Peer Reviewer will contact the attending physician the same business day. If the attending physician supplies information necessary to certify the requested service the Peer Reviewer will notify the attending physician's office that the request 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 the requested 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. Upon notification that the requested service has been non-certified, the MED-VALU nurse will place a call to the attending physician's office and once again offer an appeal of the non-certification decision. If the appeal is declined the MED-VALU nurse will document the decline of appeal in the MED-VALU computer system. The MED-VALU nurse will generate a written notice of non-certification the same day as the notification from the Peer Reviewer. If the attending physician accepts the offer to appeal, the MED-VALU Medical Director, within one business day of receipt of the appeal request, will assign the appeal review to a Peer Reviewer who is licensed in the same or similar specialty that typically provides the requested medical service being appealed. The Specialty Peer Reviewer, on the same day the appeal review is received, will place a call to the attending physician to conduct a Peer Review of the requested services. Should the attending physician office supply information necessary to certify the requested service, the Peer Reviewer will inform the attending physician the service has been certified at the time of the call. If the Peer Reviewer is unable to certify the requested medical service based upon information supplied by the attending physician, medical necessity criteria, and his/her medical judgment, he/she will notify the attending physician of the non-certification decision at that time. The Peer Reviewer will also inform the MED-VALU nurse of the non-certification of the appeal of the requested service on the same business day that the non-certification decision is rendered. Upon notification by the Specialty Peer Reviewer that the appealed service has been non-certified, the MED-VALU nurse will generated a written notice of non-certification on the same day business day. |
