Utilization review requirements are determined by plan sponsors and their payers. Refer to patients' identification cards for phone numbers to call to contact payers with questions regarding utilization review requirements and who to contact for precertification.
Providers must cooperate with all quality improvement activities and allow Midlands Choice the use of provider and practitioner performance data for quality improvement initiatives. Providers must also make available to Midlands Choice patients' medical records to process claims and perform necessary quality assurance and quality improvement programs.
Requirements will vary by plan. Services typically subject to utilization review include:
- inpatient hospitalizations (within two business days for emergency admissions)
- behavioral health and chemical dependency treatment
- imaging services (CT, MRI and PET scans)
Invasive procedures performed in physician offices usually do not require precertification.