Specialist Referrals- The Primary Care Physician (PCP) may request a consultation from a participating specialist physician at any time.The PCP determines the number of visits authorized.Specialists may include - Gynecologist, Radiation Oncologists, Ophthalmologists, Pediatric Ophthalmologists, Retinologists and Allergists etc.
Emergency Room Services -An emergency medical condition is defined as a condition that manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following:
Out-of-Plan Referrals- All out-of-Plan referrals require Plan prior authorization at Guam. These requests are reviewed on an individual basis. Determinations are made based on the patient's medical needs and the availability of services to meet these needs within the provider.
Tertiary Care Services- All referrals to plan tertiary care centers are reviewed on an individual basis.The member's medical needs and the availability of requested services within the non...
Tertiary Care Services- All referrals to plan tertiary care centers are reviewed on an individual basis.The member's medical needs and the availability of requested services within the non-tertiary care network are taken into consideration.
Discharge Planning - Patients who require continuing care after release from the hospital are identified and the appropriate services are arranged through participating home care, medical equipment and other providers.
COMPARISON AND REVIEW
The facility's Utilization Management Program may need continued review on a periodic basis in order to keep it on par with the model Utilization Management Program as described by the HealthCare Advisory Council. In keeping with these lines, the program is updated, reviewed and approved annually by a team from the HealthCare Advisory Council itself. The different types of reviews and how they lead to improvements in the quality of care is now outlined below:
Prospective Review - Using InterQuals' Level of Care Criteria all elective inpatient hospitalizations are reviewed to assure that services are provided in the appropriate setting. This ensures that the health care services and its surroundings are standardized to the required level.
Concurrent Review - InterQuals' Level of Care Criteria are utilized to evaluate the quality and appropriateness of care and to assess the medical necessity of continued stay. This review entails in the quality of care.
Retrospective Review - This review involves analysis of patient care data for medical necessity, quality of care and appropriateness of setting after care has been delivered and identifies health care service patterns of institutions, physicians and members.
AREAS OF IMPROVEMENT
Utilization management is