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23 11/2005
Concurrent Review
Concurrent review is the process of reviewing the member's inpatient confinement
to determine the appropriate level of care, discharge treatment plans and potential
alternatives to inpatient (acute) confinement. Concurrent review is a collaborative
effort between the UM Department at BCBSGa, the PCP, the admitting physician
and the Utilization Review department of the hospital or other facility.
Concurrent review is performed by the BCBSGa UM or on-site nursing staff in all
hospitals where BCBSGa members are admitted. Continued stays are reviewed by
registered nurses against Milliman CareGuide QI adopted by BCBSGa and are either
authorized for coverage or, if guidelines are not met, referred to a BCBSGa medical
director or physician reviewer for discussion. A BCBSGa medical director or
physician advisor is available by phone at (800) 722-6614 from 8 AM to 5 PM
weekdays to discuss any UM decision. The guidelines used for these
determinations are available upon request.
Retrospective Review
Claims which require review for medical necessity, procedure code bundling or
appeal issues are suspended to the Medical Review Unit. Upon receipt of the
necessary information, the nurse reviewer will evaluate the case and authorize
payment per established guidelines. If the case cannot be authorized, it is
forwarded to a medical director or a physician reviewer. Additional information is
requested from the billing provider as necessary.
Cases that were not preauthorized go through an administrative provider appeal
process. If the administrative appeal is reversed the case is sent to a nurse in the
Medical Review Unit for medical necessity review. All potential denials are submitted
to the Medical Director or appropriate board certified consultant for review. If
payment is denied, the physician and facility will receive a letter containing the
reason for denial and instructions for reconsideration. Retrospective review is also
conducted for appeals.