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Aetna Utilization Review Policy

Concurrent Review

Concurrent review encompasses those aspects of Patient Management that take place as contemporaneously as feasible during the provision of services at an inpatient level of care or during an ongoing outpatient course of treatment.

Concurrent review may be conducted telephonically or on-site at the facility where care is delivered. The concurrent review process includes:

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.

More stringent state requirements supersede this policy.

1The term "provider" as defined in the Patient Management Program Description and Patient Management 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 healthcare services, including behavioral health care organizations. Organizational providers include, but are not limited to: hospitals, nursing homes; skilled nursing facilities (SNF), home care agencies, free standing surgical centers (including free standing 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 free-standing or hospital-based. Additionally, in networks where the Medicare individual and/or group products are offered, the 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 benefit plan, or (ii) where a provider is required to comply with Aetna's patient management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.