The Utilization Review (UR) pages allow you to create and maintain the following:
During claims processing, UR uses the following to analyze the claims:
The UR studies, identifies, and analyzes patterns of patient care including length of stay and use of professional and ancillary services. In addition, these studies suggest changes needed to maintain consistently high-quality patient care and effective and efficient use of services.
Requirements for UR include reviewing certifications of need for care and written plans of care for each patient, and the conduct of medical care evaluation studies specific to each institution.
For example, you can establish parameters for assessing once-in-a-lifetime services (for example, a tonsillectomy) and/or those services having limitations (for example, two dental cleanings per calendar year).
To set up utilization reviews
A person familiar with claims processing would do the following:
The UR is the last step performed in claims processing before ND MMIS initiates claim payment. The Surveillance and Utilization Review System (SURS) performs audits on claims after they have been paid.
SURS is required by the federal government to determine fraud and abuse on paid claims. This system safeguards against:
Within SURS, the quality of Medicaid services is monitored by analyzing the use of health services by members and health services performed by providers. SURS units are responsible for the recovery of overpayments to the providers regardless of whether the overpayment was caused by the provider or the Medicaid program.
How to Add or Edit a Claim Exception
Version as of 5/16/14.
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Utilization Review System List Information