CONCURRENT REVIEW
Mercy Care Plan's Utilization Management Program encompasses activities directed
toward prospective, retrospective and concurrent utilization review. Concurrent
review occurs throughout a Member's inpatient stay. It determines the appropriateness
of the level of care and the length of stay. Retrospective review involves aggregate
and provider specific assessment of the appropriateness of medical services after
the services have been provided.
Mercy Care Plan conducts concurrent utilization review on each Member admitted to
an inpatient facility, including skilled nursing facilities and freestanding specialty
hospitals.
Concurrent review activities include both admission certification and continued
stay review. The review of the Member's medical record assesses medical necessity
for the admission, and appropriateness of the level of care using the Milliman Care
Guidelines® and the AHCCCS NICU/ Nursery/Step-Down utilization guidelines. Mercy
Care Plan medical directors make rounds one to two times per week in selected hospitals.
FUNCTIONS
Concurrent Review Nurses:
- Observation and inpatient admissions - review medical documentation on-site and
telephonically to determine medical necessity and appropriate level of care based
on Milliman Care Guidelines.
- Confirm eligibility and benefits for the member's line of business and update authorizations
in the business application system.
- Review cases that do not meet Milliman Care Guidelines with Medical Directors for
decisions on appropriate level of care or medical necessity.
- Facilitate discharge planning with facility Case Manager or Social Worker.
- Assess inpatient admissions for potential reinsurance and/or third party liability
(TPL).
- Screen for potential quality/risk/utilization management concerns and make referrals.
- Referrals initiated for: CRS, Disease Management, Case Management, DDD, ALTCS and
community resources.
- Skilled Nursing Facility Admissions - review medical documentation telephonically
to determine medical necessity and appropriate level of care based on Milliman Care
Guidelines.
Mercy Care Plan medical directors conduct medical review for each case with the
potential for denial of authorization. The medical director reviews the documentation,
discusses the case with the nurse and may call the attending or referring physician
for more information. Based on the discussion with the physician or additional documentation
submitted, the medical director will decide to approve, deny, modify, reduce, suspend
or terminate an existing or pending service.
TELEPHONE AND FAX NUMBERS
- Inpatient, 23 Hours Non-OB and OB Observation Fax Line: (602) 659-1963
- SNF Authorization Line: (602) 659-1433
- SNF Review Fax Line: (602) 414-7252
FORMS