3rd Level Review (Appeal)
  • Purpose: Used if the 2nd Level review’s decision is Denial, giving the treatment provider one final opportunity to present the rationale behind the treatment request
  • Scope: This decision is final. 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 specialty-matched peer physician (Orthopedist to Orthopedist, Pain Management Specialist to Pain Management Specialist, 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