Prior Authorization

MedSolutions’ Utilization Management program is dedicated to patient care, ensuring that each patient receives the best, most appropriate care possible while managing health care costs in the most efficient and effective manner.

For this reason, MedSolutions' prior authorization program is aimed at only the costliest, highest volume procedures -- the ones with the greatest impact on your bottom line.

MedSolutions’ service center has been designed for easy accessibility; plan physicians referring selected radiology tests simply call a toll-free phone number, fax number, or submit online through our portal, to notify MedSolutions of a proposed imaging test.

MedSolutions’ UM process is interactive and cooperative. Our extensive staff of knowledgeable medical professionals evaluates the quality and effectiveness of each requested study, in the best interest of the patient. Our program works to alter physician behavior through quality standards, self-referral controls, and physician education.

Throughout the entire process, MedSolutions emphasizes negotiation with the referring physician and applies sound medical judgment at every stage. Our commitment is to develop a customized utilization management program tailored to meet the individual operational process, systems, and medical management specifications of every healthplan we partner with.

Retrospective Review
MedSolutions’ retrospective review process compares studies performed with studies receiving prior authorization. Those without the required prior authorization are denied for claims payment and the member held harmless by participating providers. MedSolutions conducts a standard appeal review for outpatient imaging studies performed without the required prior authorization to determine medical appropriateness of the imaging study.

Appeals
Clinical peer reviewers make decisions as soon as practical and MedSolutions provides written or electronic confirmation of the appeal decision to the member, requesting provider and facility within 30 days of receiving the supporting documentation to conduct the appeal. Written confirmation will be provided within five working days of the clinical peer reviewer’s decision. Instructions are included about the health plan’s appeals process if the decision to recommend denial is made. The clinical rationale and criteria used for the decision is made available to the provider upon request. 

Annual Evaluation of Prospective Radiology Utilization Management Program
The radiology utilization management program is evaluated at least annually by the Utilization Management Committee to objectively measure the effectiveness of the program in meeting the work plan established for the department and the medical and strategic objectives of the health plan. The evaluation includes overviews of:
  • Service quality
  • Clinical quality
  • Program description review and revisions
  • Policy and procedure review and revisions
  • Accreditation processes
  • Recommendations regarding new medical technologies or new applications of existing technologies

The Director of Quality Management, working in conjunction with the Medical Director, is responsible for preparing the program evaluation and prospective work plan for the next year on an annual basis. 


 

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