Unlike ineffective permissive Utilization Review processes, only Genex delivers rigorous clinical reviews, consistently applying guidelines to all claims. This reduces unnecessary medications, surgeries, diagnostics and physical therapy.
With results in less than 1.7 days, our expedited decisions and treatment scheduling saves administrative time and burden, while ensuring the injured worker gets the care they need as quickly as possible. This easy-to-use process has minimal information requirements for the decision.
Your customized UR program will include workflows configured by medical director standards as well as individual state regulations. You can rely on consistent decisions, every time. Your program will be adapted to meet changing company needs and regulations.
Our Utilization Management Services integrated with case management, bill review, and pharmacy benefit management gives you greater control over care for injured workers and medical spend across the continuum of care.
On a national level, Genex physician resources determine the necessity and appropriateness of utilization review requests at the initial or appeal stage.
For instances when questions arise about the treatment plan or current diagnosis, there is an opportunity for a phone conversation between the case manager and/or adjuster and the clinical reviewer. Additionally, we offer an opportunity for a phone conversation between the treating provider and the peer clinical reviewer for instances when the claimant has been out of work longer than optimum disability duration, the provider refuses to release the medical information to the case manager, conflicting medical information is received, and the provider refuses to address causal relation when co-morbidities exist.
Genex has been accredited by URAC in Workers’ Compensation Utilization Management since 1996. To obtain this accreditation, we went through an in-depth and rigorous evaluation process. Learn what it takes to achieve URAC accreditation.
You can rely on Genex’s jurisdictional expertise to meet all regulatory requirements. In California, Genex is positioned to meet and exceed the requirements of Senate Bill 1160, particularly the accreditation mandate. Click here to access Genex’s California Filing and Policies and Procedures.
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The Genex grievance process addresses all formal complaints regarding non-clinical and non-determination-related Genex processes or services. The grievance process does not address the clinical decision, but shall instead focus on concerns with the process or people involved in developing the determination. Examples of grievances could be complaints that the UR decision was not done within time frames established by the Labor Code or that the physician who rendered the determination was not licensed.
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