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Utilization Review Criteria Update

Medical Director Availability After an Adverse Determination

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Medical Director Availability After an Adverse Determination

Our medical directors use established evidence-based criteria to evaluate requests for procedures and services, including but not limited to surgery, testing or inpatient admissions, continued hospital stays, care in skilled nursing or rehabilitation facilities, and requests for home care and durable medical equipment. They also use eligibility, benefits, medical necessity, and appropriateness of the type, level and setting of care criteria to make their determinations.

In the event that a medical director issues an adverse determination after evaluating a request, verbal and written communications required by regulatory guidelines are delivered to the provider and member. Medical directors may rescind the adverse determination if additional information establishes medical necessity. If the adverse determination relates to a continued hospital stay, a reconsideration will be conducted only if the patient has not been discharged. If the patient has been discharged, a formal appeal must be filed with the Grievance and Appeals department as outlined for the specific member in the Dispute Resolution section of the Provider Manual:


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