Project goal and objectives – Proposer shall conduct secondary utilization reviews for all patients that require inpatient stay but do not meet criteria using the state-approved InterQual or MCG software. Such services shall include the provision of remote physician advisor services for a timely response of 60 min or less on Emergency Department cases and a response of less than two hours for medical necessity. Physician interaction with direct conversations between hospitals’ clinicians and physicians to physician for concurrent reviews and ongoing education. Receiving referral and providing timely response to secondary review, appeals, progress and performance reporting within a context of open and available communication with hospital’s physicians to discuss level of care of hospitalized patients when there is a disagreement between physicians advisor and hospital physician. Physicians may be responsible for peer to peer reviews to mitigate payor denials as well as level of care reviews for all payors. Physicians will attend a quarterly Utilization Report Committee meeting.
