These clinical reviews are conducted prior to a claimant’s episode of care (based on the jurisdiction they can also be termed Pre-Authorization or Pre-Certification).  This facilitates the proactive management of clinical resources, either mandated by the jurisdiction or the payer, and are used to bring an injured worker back to health and return them to work. This series of reviews address a single question of medical necessity but cannot address causal relatedness. In a non-UM mandated state, a Claims person or a Nurse Case Manager can initiate this referral, otherwise this referral is initiated by the UM/UR unit.

• 1st Level Review
  The first step in the UM process
• 2nd Level Review
  The second step in the UM process, only initiated if the 1st Level Review did not either Approve or Technically Deny the treatment request
  
• Reconsideration
  Used if the 2nd Level review is unsuccessful in obtaining discussion with the treatment provider or there is additional made available about the request
• 3rd Level Review (Appeal)
  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