Concurrent review

Medical - concurrent review

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

The concurrent review process includes:

• Obtaining necessary information from appropriate facility staff, practitioners and providers¹ regarding the clinical status, progress and care being provided to members.
• Assessing the clinical condition of members and the ongoing provision of medical services and treatments to determine benefits coverage.²
• Notifying practitioners and providers of coverage determinations in the appropriate manner and within the appropriate time frame.
• Identifying continuing care needs early in the inpatient stay to facilitate discharge to the appropriate setting.
• Identifying members for referral to covered specialty programs, including Aetna Health Connections^SM Case Management, 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 on site at the facility where care is delivered.

Discharge planning is an integral part of inpatient concurrent review that begins at the time of notification and continues throughout the hospital stay.

Requests for extension of care
Provider requests for extension of coverage for a course of inpatient or outpatient treatment received prior to the expiration of the current certified number of days/visits/treatments are handled following the urgent concurrent review coverage request time frames.

More stringent state requirements supersede this policy.

¹The term “provider,” as defined in the Aetna Health Connections: Utilization Management Program Description and Medical Operations policy/procedure, is used collectively to mean a practitioner/professional who provides health care services and is usually required to be licensed as defined by applicable law or regulation, and/or an organizational provider, an institutional provider and/or supplier of health care services, including behavioral health care organizations. Organizational providers include, but are not limited to, hospitals, nursing homes; skilled nursing facilities (SNFs), home care agencies, freestanding surgical centers (including freestanding abortion centers and birthing centers). Behavioral health organizations include, but are not limited to, mental health and chemical dependency hospitals, residential treatment facilities, partial hospital programs, intensive outpatient programs and clinics. Behavioral health organizations can be freestanding or hospital based. Additionally, in networks where the Medicare individual and/or group products are offered, organizational providers include laboratories, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech pathology providers, and providers of end-stage renal disease services.

²For these purposes, "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.