Purpose: The second step in the UM process, only initiated if the 1st Level Review did not either Approve or Technically Deny the treatment request
- Scope: Several decisions can be rendered by the peer physician:
- Approval: The treatment provider can pursue the requested regimen
- Modified with Agreement: The peer physician recommends a modification to the requested treatment regimen and the treatment provider agreed to implement as modified
- Denial: The requested regimen is not approved for clinical reasons (not medically necessary or reasonable)
- Reviewer: A discipline-matched peer physician (MD to MD, PT to PT, DC to DC, etc.)
- Inputs:
- Referral form that outlines the request
- Medical records pertinent to the requested treatment
- Output from the 1st Level review
- Clinical experience of the peer physician
- 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