utilization-review-assistant

Medical necessity evaluation is performed by inputting structured clinical data, admission details, and treatment plans to assess patient information against InterQual, Milliman, and CMS criteria for objective utilization review decisions.

Level of care determination analyzes concurrent patient data against clinical criteria to recommend appropriate care settings, such as ICU, Med-Surg, or SNF, evaluating if a patient meets requirements for step-down to a lower level of care.

Yes, the utilization review assistant supports retrospective utilization reviews and peer-to-peer appeals by evaluating admission and continued-stay criteria, length-of-stay justification, and medical necessity against structured payer information and clinical benchmarks.

Length of stay justification is generated by analyzing the current inpatient stay against clinical benchmarks and treatment plans to determine ongoing medical necessity and identify specific barriers preventing patient discharge.

You need to provide structured clinical data, admission details, treatment plans, and payer information to generate a comprehensive utilization review output evaluating medical necessity and level-of-care appropriateness.

Yes, the tool applies admission and continued-stay criteria assessment for concurrent or retrospective utilization reviews, evaluating medical necessity and level-of-care appropriateness throughout the patient stay.