Create and Manage Utilization Reviews

Utilization Reviews, often called Authorization Plans or U/R Plans, are needed by most payers before inpatient treatment begins. The collection and entry of U/R plan details typically happen during benefits verification.  Once a U/R plan is completed, the specified services that require U/R approval can be documented in the attendance calendar. Let's review this process together!

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.

Plan Types

There are three types of plans that can be created in the U/R section of the patient's treatment episode: traditional U/R plans, standalone authorizations, and private-pay plans for organizations with the patient billing module.

• Traditional U/R plans include pertinent information for the claim, such as the authorization number, rendering provider information, and facility details. U/R plans can only be created for U/R-required services in the RCM and for Levels of Care in the EMR.
• Standalone authorization plans are used for payers that require pre-authorization before reimbursement for standalone services.
• Private-pay plans are only available to organizations with the Patient Billing module. These plans are used to create special rates for standalone or private-pay services. Additionally, private-pay plans are used to record and bill private-pay patients for organizations with the EMR integration.

Create a Utilization Plan

Utilization Plans, Standalone Authorizations, and Private-pay plans can be created in the U/R section of the patient's treatment episode. Let's review each workflow to determine which is best for you!

1. In the Patients section, locate the patient's name and click the U/R quicklink. 
2. Then click Create Utilization Plan.
3. Next, select the plan type from one of the following:
   • Auth Required Plan: Use this plan type to record U/R-required services and include authorization information in the claim.
   • Standalone Plan: Use this plan type to include authorization information in the claim for standalone services.
   • Private Pay Plan: Use this plan type to record all service types as private pay treatments.
     
4. Enter the Start Date and End Date in their respective fields.
   
5. Then select the Facility from the drop-down.
   

• Let's go over the remaining steps for creating the U/R Plan!
  6. When applicable, assign a Case Manager, then update the Review Type drop-down.
  7. Select the Service from the drop-down, then update the Service Billing Profile from the default when desired.
  8. Choose the Rendering Provider from the drop-down.
  9. Then, when applicable, update the Referring Rendering Provider and Billing Provider fields.
  10. Under the Primary Payer section, update the Insurance Payer drop-down.
  11. Next, enter the number of units and update the Authorization Status field.
  12. Enter the Authorization Number.
  13. Then enter a Review Date in the field to create a reminder in the Management Center.
  14. Add any pertinent Payer Notes when applicable.
  15. If the patient has secondary insurance, click Add Secondary Payer and repeat steps 4 and 10-14. Repeat this process if the patient has a tertiary insurance.
  16. Once all fields have been filled out, click Create Utilization Plan to complete the process.
• Let's go over the remaining steps for creating a Standalone Plan!
  6. Select the Service(s) from the drop-down.
  7. Then select the Insurance Payer from the drop-down.
  8. Next, enter the number of Units and update the Authorization Status drop-down.
  9. Enter the Authorization Number.
  10. Then enter a Review Date in the field and add any pertinent notes when applicable.
  11. Once all fields have been filled out, click Create Utilization Plan to complete the process.
• Let's go over the remaining steps for creating a Private Pay Plan!
  6. Select the Service from the drop-down. Only Standalone or Non-medical services will be available for selection.
  7. Then enter the Unit Rate. This field is required even if the service has a private-pay rate established in the facility.
  8. When applicable, update the Case Manager, and include the Rendering Provider information.
  9.  If desired, add any pertinent notes and enter a review date.
  10. Finally, click Create Utilization Plan to complete the process.

Create U/R Plans In The Work Center

U/R plans can be created in both the patient's treatment episode and the Work Center. Click below to learn more about creating a U/R plan in the Work Center!

• Let's review how to create U/R plans in the Work Center!
  1. Navigate to the Work Center and click the Utilization Management tab.
  2. Next, set the Case Manager drop-down to the desired setting.
     
  3.  Then update any remaining filters, if applicable, before clicking Update.
     
  4. Locate the patient and click on the three dots.
     
  5. Then click Create Utilization Plan.
  6. Update the Review Type field when applicable, and enter the start and end dates.
  7. Next, select the Facility from the drop-down to generate the Services list.
  8. Then select the service name.
     
  9. The system will use the defaulted billing profile configured in the service. However, this field can be changed to use any service billing profile created for the service.
  10. Select the Rendering Provider from the drop-down and include a Referring Rendering Provider and their role when applicable.
      
  11. Enter the number of authorized units and change the U/R Follow-up Date field when desired.
      
  12. Next, select the Primary Payer name from the drop-down.
  13. The system will default the Primary Authorization Status to Completed: Authorized. However, this field can be updated as needed.
  14. Finally, enter the authorization number and click Save to complete the process.
      

Manage Utilization Plans

If the U/R plan contains incorrect information but correct options exist (e.g., the wrong rendering provider is selected, but it's already in the system), you can correct it directly in the U/R 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.

Frequently Asked Questions

Click below to review answers to some of our more frequently asked questions.

• The RCM is designed to combine plans when both authorization numbers are identical, regardless of plan type. In addition to the authorization number, both must have compatible billing profiles and plan information.

  Combine Auth. Required Plans and Standalone Authorizations
  Service Billing Profile	Both Plans
  Both profiles have the same preferred claim type. Both profiles allow multiple services per claim. The Place of Service is the same for professional claims. The Bill Type Prefix is the same for institutional claims. Both profiles match in what they allow/disallow per claim, e.g., Allow For Multiple Months, etc	Each plan has the same authorization status. Each plan has the same authorization number. The Rendering Provider in the plan must match the Rendering Provider selected when recording the standalone service. Both Services are rendered in the same facility. The Payer and sequence (primary, secondary, etc) is the same.

  Combine Auth. Required Plans
  Service Billing Profile	U/R Plan
  Both profiles have the same preferred claim type. Both profiles allow multiple services per claim. The Place of Service is the same for professional claims. The Bill Type is the same for institutional claims. Both profiles match in what they allow/disallow per claim, e.g., Allow For Multiple Months, etc	Each plan has the same authorization status. Each plan has the same authorization number. Each plan references the same rendering provider. The Payer and sequence (primary, secondary, etc) is the same. Both Services are rendered in the same facility.

  Combine Standalone Plans
  Service Billing Profile	Standalone Plan
  Both profiles have the same preferred claim type. Both profiles allow multiple services per claim. The Place of Service is the same for professional claims. Both profiles match in what they allow/disallow per claim, e.g., Allow For Multiple Months, etc	Each plan has the same authorization status. Each plan has the same authorization number. The Payer and sequence (primary, secondary, etc) is the same. Both Services are rendered in the same facility. Both Services reference the same rendering provider in the Attendance Calendar.