4 Things You Should Know Before Calling for a Prior Authorization

Utilization Review

Utilization Reviews bridge the gap between providers, payors and patients. They give the provider the opportunity request authorization for a treatment, and the insurance company the opportunity to determine whether or not the treatment is medically necessary. It is the Utilization Review Specialist’s job to advocate for the patient, so they are given access to the type of care they need.

Utilization Review’s also help guarantee payment from the insurer to the provider. Without proper case management, your patient’s insurance company is unlikely to authorize payment for the type of treatment that they need. Particularly with behavioral health services, if treatment is not authorized, the insurance claim will be denied, causing huge financial hardship for the physician or facility. Proper utilization review requires comprehensive intake assessments, knowledge of the patient’s past and current mental state and timely follow-up calls to extend their treatment, if necessary.

Utilization Review Best Practices

Call in the case within 24 hours of admission.

Refer to relevant documents that you received during the intake assessment.

Track the number of days your patient has been given for treatment. Monitor your patient’s progress and if they need more treatment, call in the request days in advance.

Stay organized. Keep a separate file for each patient with a record of any details or critical information you received from the case manager.

Want to know how much money you will get from a policy before you complete the Utilization Review?

Get An Insurance Reimbursement Calculator

For more information on this topic and much more, view our Behavioral Health Guide to Quick and Accurate Claims Processing. You can also download the PDF format by clicking on the image below