Utilization Review

In today's market with a growing emphasis on Population Health Management and Pay for Performance (P4P), Healthcare Payers must support all types of services requests and reviews (prospective, concurrent, and retrospective) to ensure their members are getting the right level of care while maintaining a high standard.  BIG's Utilization Review application simplifies Healthcare Payers' process for receiving referral requests from members and providers that are seeking authorization for medical services outside of the scope of what is provided by their Primary Care Provider. It standardizes the process of documenting the request for services and leverages configurable business logic to determine medical necessity based on the information provided in the request, and designate the appropriate outcome. This ensures that clinical resources are reviewing the right requests in a timely manner.

Features and Functionality:

  • Intake entry forms to capture requests received
  • Search capabilities for industry standard diagnosis and service code libraries to document encounter details
  • Individual worklists for clinicians with calculable due dates based on request attributes
  • Ability to re-assign requests to other queues/clinicians
  • Review and update request details, including determination of the request outcome
  • Extend previously approved or denied requests and submit for additional review
  • Generate member letters summarizing request outcome
  • Reporting dashboard that summarizes request details
  • Create and manage decision logic to automatically approve, deny, or pend requests based on request attributes
  • Configure work queue auto assignment based on request attributes
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