Health Utilization Management Standards
The Health Utilization Management Standards require an organization to establish and implement a three-step process to determine if a proposed medical treatment or service is medically necessary. Licensed health professionals, such as nurses, must perform the first step - Initial Clinical Review
If the proposed service cannot be approved during initial clinical review, then the case must be referred to step two of the process -
Peer Clinical Review
A physician who is qualified to render a clinical opinion about the proposed medical service generally must perform peer clinical review. However, if the treating provider is a non-physician, then a similar provider may also perform peer clinical review. For example, if the treating provider is a chiropractor, then peer clinical review may be performed by a chiropractor. Regardless of the type, a provider who performs peer clinical review must be available to discuss review determination with the treating provider.
As with initial clinical review, if peer clinical review results in a certification, then the utilization management process ends for that case. However, if peer clinical review results in a non-certification, the treating provider and the patient have the right to access step three of the process –
Appeals Consideration
Clinical peers that are board-certified must consider appeals and who are in the same profession and similar specialty as typically manages the medical condition under review and who were not involved in the initial review decision. Either the patient or the treating provider may initiate appeals consideration. For cases involving ongoing or imminent medical care, the organization provides for an expedited appeals consideration mechanism.
Throughout the utilization management process, the UMO utilizes explicit clinical review criteria based on sound clinical principles and processes and are reviewed and revised on a periodic basis. Upon request, the UMO discloses to the patient or treating provider the criteria upon which a non-certification decision was based.