Administered by highly trained healthcare professionals using medically accepted clinical review criteria, GENEX utilization review services validate the medical necessity and appropriateness of the treatment plan. The process is initiated upon receipt of a request for certification of a service or procedure from the treating provider, facility rendering service, or patient/authorized representative.
Conducting the initial clinical review, an experienced GENEX nurse reviewer determines if the proposed treatment plan is medically necessary and appropriate. For cases that demonstrate medical appropriateness based on clinical review criteria, our nurse reviewer recommends certification of the proposed treatment plan and issues an authorization number. If the treatment plan is not supported by 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 utilization reviews include:
- Concurrent Review
- Prospective Review
- Retrospective Review
- Physical Therapy UR
- Pharmacy Review/Drug Utilization Review
Monthly Quality Assurance Closed Case Audit
All Utilization Review Branch Managers and Supervisors conduct monthly quality assurance audits of utilization review cases closed during the previous month. Data entry, nurse reviewer, and peer clinical reviewer/physician advisor performance are audited to evaluate compliance with established utilization review process performance expectations and standards, assuring our clients receive the highest degree of professional medical accuracy.