After you have set up your system lists and exception codes, you must establish the medical parameters that are associated with the medical criteria for procedure and revenue codes used in the utilization review (UR) process. The medical parameters consist of two types of parameters: limit parameters and contraindicated parameters (also called contraindicated limits). Contraindicated parameters are used to set up medical criteria for a condition or factor that serves as a reason to withhold a certain medical treatment.
Diagnosis codes can be included or excluded from medical parameters when the procedure or revenue code limits are established. The utilization review process is performed at the procedure and revenue code level. A diagnosis code can be used to further define the medical parameter limits.
Before medical parameters can be set up, an exception code must exist to support them.
Limit parameters and contraindicated parameters have only one set of parameter dates associated with them. The set consists of the following:
Age ranges for the limit and contraindicated parameters can differ.
When the utilization review is run for a contraindicated parameter, the medical parameter identifies whether history claims should be checked before the current claim, after the current claim, or both.
Medical parameters also further delineate whether its associated data elements must be the same, must be different, or not considered.
You can search for existing UR medical parameters by line of business, code type, UR parameter number. or description.
You can add or edit UR medical parameters that contain limits or contraindicated parameters. Contraindicated limits are set up by populating a contraindicated parameter.
You can delete a limit parameter number or contraindicated parameter number.
How to Search for a UR Medical Parameter
How to Add or Edit a UR Medical Limit Parameter
How to Replicate a UR Medical Limit Parameter
How to Delete a Medical Limit Parameter
How to Add or Edit a UR Medical Contra Parameter
How to Replicate a UR Medical Contra Parameter
How to Delete a Medical Contraindicated Parameter
Search UR Medical Parameter Page
UR Medical Limit Parameter Number (UR Medical Limit Parameter Number Tab) Page
UR Medical Limit Parameter Number (UR Medical Limit Include/Exclude Tab) Page
UR Medical Contra Parameter Number Page
Version as of 5/16/14.
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