Utilization Review

Pre-Authorization Review

Utilization review (UR) is a requirement for certain medical procedures in many jurisdictions. UR provides the assistance necessary to manage the risk of unnecessary care, while approving appropriate care promptly. This is done in an effort to improve function and productivity, and to monitor ongoing care to maximum improvement. UR is an important tool for containing costs related to overutilization of treatment and/or excessive testing and appropriateness of treatment.  When a practitioner provides the right care, at the right time, at the right place, the final outcome is "right" for all parties.  Such care results in timely recovery, increased savings and a “fast track” to maximum medical improvement (MMI).

Using the services of CareWorks, MCS, it is recommended that the following procedures be subject to review prior to authorization:

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An Effective Tool In Managing Medical Services, Utilization and Costs

CareWorks, MCS' Utilization Review team includes an experienced staff of Registered Nurses, Physicians, Medical Directors, and large panel of Certified Peer Reviewers.  The team uses recognized guidelines and treatment protocols to determine if a claimant’s medical care and treatment was reasonable and necessary.  When the team conducts the review, if the treatment was appropriate, the UR nurse certifies the treatment.  If the UR nurse cannot certify the treatment, the claim will be referred to MCMC, LLC's Peer Review panel. MCMC, LLC continues to managed the peer review process for ASC.

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"The claims handling service experience OSIG receives from ASC is very positive - claims are handled effectively and effeciently allowing OSIG to provide better services to our member schools." Oklahoma Schools Insurance Group (OSIG)