Reconsideration
- Purpose: Used if the 2nd Level review is unsuccessful in obtaining discussion with the treatment provider or there is additional made available about the 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 and 2nd 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
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
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