Concurrent Review

Concurrent review includes utilization management activities that take place during an inpatient level of care or an ongoing outpatient course of treatment (for example, behavioral health partial hospital program [PHP], behavioral health intensive outpatient program [IOP], home health care [HHC] services).

The concurrent review process includes:

• Obtaining necessary clinical information from facility staff, practitioners and providers 
• Using the clinical information provided by facility staff, practitioners and providers to determine benefits coverage¹
• Notifying facility staff, practitioners and providers of coverage determinations in the appropriate manner and time frame
• Identifying discharge planning needs at the beginning of the inpatient stay and reassessing these needs throughout the stay
• Identifying and referring potential quality of care concerns and patient safety events for additional review
• Identifying members for referral to covered specialty programs, including Aetna Health Connections^SM case management and disease management, behavioral health, National Medical Excellence^® and women’s health programs, such as the Beginning Right^® Maternity Program

Concurrent review may be conducted by phone, fax or, as applicable, on-site at the facility where care is delivered. 

More stringent state requirements may supersede the requirements of this policy.

^{1For the purposes of this policy, "coverage" means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is required to comply with Aetna's utilization management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.}