Prior Authorization
Prior Authorization of Costly Medical Care
PMR is the gateway to care that is considered likely to be costly based on the diagnosis. The benefit plan requires that the participant (patient) or their physician contact the utilization review nurse prior to various procedures and for specific diagnosis. Those generally include hospitalization of any type, home health care, and all types of therapy. The diagnosis would include heart problem, cancer, diabetes, maternity as well as any others. These are the areas that medical review has the greatest impact upon. Medical necessity of the treatment plan is reviewed with the attending physician and approved or an alternate care pattern or setting suggested. This virtually eliminates the duplication and/or use of inappropriate procedures and testing or the inappropriate care setting.
Back to Physicians Medical Review Executive Summary
