1. Prospective review
Occurs before the services are rendered.
• If the payer requires preauthorization, the request would trigger a prospective utilization review.
• A preadmission case manager should review scheduled surgical cases to determine appropriate level of care and ensure that there are no pre-op days not meeting medical necessity.
• Review National Coverage Determination to assure that the documentation in the record demonstrates that specific procedures are appropriate.
2. Concurrent review
Occurs while services are being rendered.
• If a provider requests hospital days beyond those approved, a concurrent review would be triggered.
• Medicare expects that case managers manage the medical necessity of its beneficiaries.
• DRG reimbursed cases should be reviewed for medical necessity.
• Episodes of care covered under a bundled payment arrangement should be reviewed.
• Case managers should conduct a review of all concurrent denials.
• Cases of unfunded and underfunded patients should be reviewed concurrently.
3. Retrospective review
Occurs after services have been rendered.
• Case managers should review cases when a short stay patient is admitted and discharged before a medical necessity review has been conducted.
• A denial is issued after a patient has been discharged.
Source: Case Management Concepts
This chart shows the types of payer reviews case managers typically perform.
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