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Utilization Management - Prior Authorization
 
What is Utilization Management?


DDHC follows the nationally recognized criteria of Milliman or InterQual. The Utilization Management and Quality Management committees, made up of physicians from each sub-specialty, are responsible for review and approval of these criteria on an annual basis.

DDHC Medical Management Department reviews the request for:

•Member eligibility at the time of service
•Benefit and Coverage guidelines
•Use of appropriate providers
•Medical necessity of the procedure or proposed care
•Appropriate setting for the procedure or inpatient admission


Pre-Admission Review

The DDHC Medical Management Coordinator compares the request to Milliman guidelines or InterQual criteria for the specific diagnosis or condition, the appropriateness of the services being rendered and the initial length of stay. Decisions are based solely on medical information obtained at the time of the review determination.

Concurrent Review

Continued stay reviews are conducted to determine if InterQual guidelines are met. If the initial chart review indicates that guidelines are met, the Medical Management Coordinator will assign continued length of stay and communicate notification of approved inpatient days within 24 hours of the request.

Elective Admissions and Outpatient Procedures

All elective hospital admissions including surgical procedures and certain outpatient procedures must be precertified by the DDHC Medical Management Department. This precertification procedure allows providers and DDHC to work together to determine the most efficient use of medical services.

 

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