1st Level Review
  • Purpose: The first step in the UM process
  • Scope: Since a non-physician conducts this review, only three decisions can be made:
    • Approval: The treatment provider can pursue the requested regimen
    • Technical Denial: Regulations were not followed by the treatment provider and thus the request is denied due to administrative reasons
    • Elevate: A peer physician needs to be engaged to look at what the Evidence Based Medicine cannot approve
  • Reviewer: A Nurse Case Manager or other non-physician
  • Inputs
    • Referral form that outlines the request
    • Medical records pertinent to the requested treatment
    • Evidence Based Medicine (sometimes defined by the Jurisdiction)
  • Discussion: Unless otherwise stipulated by the customer or statute, the treatment provider is contacted and receives a copy of the report
NOTE: PRIUM can either provide these turnkey services or integrate with a client’s existing staff/process

 
PRIUM Manages

  • Compliance with the unique requirements for each jurisdiction, including time service
  • The Utilization Review Accreditation Committee (URAC) model that is generally accepted as best practices
  • Any special requirements from the customer
  • Accreditation and licensing of reviewing physicians
  • Appropriate assignment per Jurisdictional and UM requirements