Below are a few enhancements to the Utilization Review process.
PEER TO PEER REASON CODES
Under UTILIZATION REVIEW>PA AND UNIT AUTHS, there is an option to MAINTAIN PEER REVIEWS. This is located under MOREINFO>MAINTAIN PEER REVIEWS.
Once in the screen, there is a button POST REVIEW.
Once in this screen there is a REASON option. To assess the REASON options, select F3 to bring up the list. Two enhancements have been added to this option.
- The options can now be unique to your facility. For the facilities who control the MUCODES, there is now an option named PeerRvwRsn. The user can add as many REASONS as needed. If your facility does not maintain the MUCODES, our support team can set this up for your facility.
- If one of the reasons is RESCHEDULED, and this reason is selected, a REVIEW NOTE must be added before the user can leave this screen. If a NOTE is not entered, the user will see the ERROR below and can not leave the screen without adding a NOTE.
PATIENT RECAP
The PEER TO PEER REVIEW info has been added to the PATIENT RECAP report. See a sample of a PATIENT RECAP below.
PEER REVIEW NOTES
The PEER REVIEWS are tracked by running the DENIAL REPORTS. The DENIAL REPORT is located under REPORTS>UTILIZATION REPORT>HOPSITAL (or CLINIC)>DENIAL. This program has five different reports. Two of these reports pertain to PEER REVIEWS and both will print the PEER REVIEW notes.
INSURANCE RANK IN THE DENIAL REPORTS
All the DENIAL reports now show the RANK of the payor as indicated on the patient’s insurance screen. i.e. RANK 1, 2, 3, etc. See this information on a snippet of the sample report below.
| Patient | Svc | TProg# | MR/Admit | Att. MD | Auth Payor | Auth Payor Rank | Current Payor |
| Cox, Thelma | IP | 102 | 014668-2 | Smith, Sam | Aetna | 1 | Aetna |
| Cox, Thelma | IP | 102 | 014668-2 | Smith, Sam | Aetna | 1 | Aetna |
| Cox, Thelma | IP | 102 | 014668-2 | Smith, Sam | Aetna | 1 | Aetna |
| Cox, Thelma | IP | 102 | 014668-2 | Smith, Sam | Aetna | 1 | Aetna |
NEXT REVIEW
When posting an authorization, the user has always had the option to enter in a NEXT AUTH REVIEW date. If your facility would like this to be a mandatory field for In Patients, there is now a parameter that the support team can add named MandatoryIPNxtRvw=YES.
Once this parameter is added, if a user adds an authorization on an In Patient without adding a NEXT REVIEW DATE, an ERROR will display. The user will not be able to leave the screen without adding a date.
POST APPEAL ACTION CODE and SUBMITTED date
Once in the PA AND UNIT AUTH screen, the user has had the option to post APPEAL information. This is located under MOREINFO>SHOW AUTHORIZATION HISTORY.
Once in the AUTHORIZATION HISTORY SCREEN, select POST APPEAL. The RECORD APPEAL screen will display.
- ACTION CODE - The facility has the option to add pre-defined codes and descriptions. This can be maintained by the facility, or the support team, by adding the MUCODE of AppealAction. Note, the ACTION TAKEN which is a free text field, is still an option.
- The second enhancement is the option to enter in a SUBMITTED DATE. See screen shot above.