Aetna Utilization Review Policy
Concurrent Review
Concurrent review encompasses those aspects of utilization management that take place during an inpatient level of care or during an ongoing outpatient course of treatment.
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 coverage2.
- 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 ConnectionsSM Case Management, Disease Management, Behavioral Health, National Medical Excellence and Women’s Health Programs, such as the Moms-to-Babies Maternity Management Program®.
Concurrent review may be conducted by phone or on site at the facility where care is delivered.
Discharge planning is an integral part of inpatient concurrent review. Recognizing and planning for discharge needs 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 clinically urgent inpatient or outpatient treatment received prior to the expiration of the current certified number of days/visits/treatments are handled as an urgent concurrent review request.
- Provider requests for routine extension of an ongoing outpatient course of treatment are handled as a new precertification request.
More stringent state requirements supersede this policy.
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