Utilization Review | GENEX Services

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Utilization Review

Reduce UR costs and control medical spend while remaining compliant with regulations

GENEX Utilization Review (UR) Services help workers’ compensation employers and payors meet utilization review regulatory requirements while reducing administrative costs, ensuring recommendations are defensible, streamlining the approval and referral decision-making process, and accelerating the delivery of approved, appropriate medical care.

GENEX’s UR Services offer a customized UR Fast TrackTM approval program that expedites authorization for requests that do not require clinical review to help reduce UR costs. Our UR services seamlessly integrate with our Case Management, Bill Review, and Pharmacy Benefit Management systems to help ensure payment for only authorized medical treatment. These services also provide simplified scheduling with specialty networks resulting in early treatment which improves outcomes.

How GENEX Utilization Review Service Works

Upon receiving a request for certification of a service or procedure from the treating provider, facility rendering service, or patient/authorized representative, a highly trained healthcare professional uses medically accepted clinical review criteria to validate the medical necessity and appropriateness of the treatment plan.

For cases that are deemed medically appropriate based on clinical review criteria, GENEX’s nurse reviewer recommends certification of the proposed treatment plan and issues an authorization number. If the treatment plan is not appropriate according to the clinical information provided, the case is referred for peer clinical review. Only a peer clinical reviewer/physician advisor can render a non-certification recommendation.

GENEX conducts monthly quality assurance audits to ensure our customers receive the highest degree of professional medical accuracy. The audits are conducted by all utilization review branch managers and supervisors to evaluate compliance with the established utilization review process performance standards and expectations.

GENEX Utilization Reviews include:

      • Concurrent review
      • Prospective review
      • Retrospective review
      • Physical Therapy UR
      • Pharmacy review/Drug Utilization review

Click here to learn more about GENEX Utilization Review Services.