Create and Manage Utilization Reviews

Utilization Reviews, also known as Authorization Plans or U/R Plans, are required by most payers before inpatient treatment can be rendered. Gathering and entering U/R plan information usually occurs during the verification of benefits process.

After a U/R plan is completed, the U/R-required service listed in the plan can be recorded in the attendance calendar.

User Permissions

Organization Users and Managing Organization Users require edit-level permissions to create and manage U/R plans. Organization Admins and Managing Organization Admins can create and manage U/R plans without additional configuration required. For more information on creating and managing user profiles, click here.

Create a Utilization Plan

Utilization Plans can be created in the U/R section of the patient's treatment episode or in the U/R section of the Work Center. Let's review each workflow to determine which is best for you!

Note: If a U/R plan exists but additional units were authorized using the same authorization number, we recommend extending the dates of the existing plan, as opposed to creating a new one, to ensure that claims with DOS that span both plans do not split during the claim creation process.

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  1. In the Patients section, locate the patient's name.
  2. Then click the U/R quicklink.
     
  3. Next, click Create Utilization Plan.
     
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  1. Navigate to the Work Center and click the VOB and U/R tab.
  2. Next, click the U/R subtab and update the Case Manager dropdown to the desired setting.
     
  3. Locate the patient and click Create Utilization Plan.
     

4. Update the Review Type and enter the start date and end date of the plan.
   
5. Next, choose the Facility where the treatment will be provided. This choice will determine the services available for the plan.
   
6. Click the Service dropdown and then select the Service Billing Profile to associate with the plan.
   
7. And select the Rendering Provider dropdown and update the default Billing Provider when applicable.
   
8. Enter the number of authorized units and update the Treatment Episode UM Follow-Up Date to trigger a review notification before the U/R plan expires.
   
9. Next, update the Primary Payer and Primary Authorization Status to any of the following:
   • Authorized: The payer has approved the medical necessity of the treatment being requested and provided an authorization number.
   • Denied: The payer has rejected the medical necessity of the treatment being requested.
   • Not Required: The payer does not review for medical necessity for this level of care. Treatments do not require authorization, and the patient will receive benefits for this treatment based on medical necessity. The payer may request medical records at a later date to investigate the medical necessity of the treatment.
   • Pending: A placeholder status that is used while waiting to hear back from the care manager about approval or denial of the requested treatment. Important: Claims cannot be submitted while the authorization is in this status.
   • Required – Not Obtained: This is used when authorization has never been obtained. The medical necessity can be appealed at any time.
     
10. Then enter the Primary Authorization Number and click Save to complete the process.
    

Secondary and Tertiary Authorizations

If the patient has a secondary and/or tertiary payer, the system will automatically generate optional fields for that information to be added after the primary authorization information is entered.

Manage Utilization Plans

If the U/R plan contains incorrect information but correct options exist (e.g., a wrong rendering provider is selected but already in the system), you can correct it directly in the UR plan. Changes that can be made include the Facility, Service, Service Billing Profile, Rendering Provider, Billing Provider, Authorized Status, or Authorization Number.  For more information on updating existing U/R plans, click here.