Review capabilities
Concise, defensible determinations supported by current clinical information, applicable benefit language, plan policy, and recognized criteria.
Medical necessity and level of care
- Prospective, concurrent, and retrospective review
- Inpatient versus observation determinations
- Continued-stay and discharge-readiness assessment
- Procedures, therapies, and requested services
Prior authorization and medication coverage
- Clinical eligibility and policy alignment
- FDA-approved labeling and guideline review
- Step-therapy, prerequisite, and exception analysis
- Current peer-reviewed literature when required
Criteria may include MCG, InterQual, CMS guidance, NCDs and LCDs, CA MTUS, MTG, ODG, and client-specific policy.