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            Conduct a Medical Director Review of the Authorization Request

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            Conduct a Medical Director Review of the Authorization Request

            As a medical director, you’ve the final say on an authorization request. Similar to the utilization management nurse, you determine the medical appropriateness of inpatient, outpatient, and pharmacy services by reviewing clinical information and applying evidence-based guidelines.

            Required Editions

            Available in: Lightning Experience

            Available in: Enterprise and Unlimited Editions with Health Cloud
            User Permissions Needed
            To conduct a medical director review: Health Cloud Utilization Management, OmniStudio User, and RuleEngine Runtime permission sets

            Perform a comprehensive clinical review of the request and ensure quality parameters are met by:

            • Verifying member eligibility, member plan coverage benefits and limits, diagnosis details, and previous requests
            • Ensuring that the right quantities of requested services are approved based on the member’s benefit limits
            • Requesting supporting documents for gathering additional inputs
            • Verifying comments from previous reviewers
            • Clearly and accurately maintaining notes about each service and document
            • Documenting all communication and decision-making, ensuring that the member and provider can easily refer to and understand your decision
            • Meeting appropriate turn-around times for clinical reviews
            • Communicating the final decision, either Approval or Denial, to the provider and member.
            1. From the App Launcher, find and select the Utilization Management for Payers app.
            2. Select the case record to review.
            3. Click Start Medical Director Review.
            4. Verify information such as member details, requesting provider details, clinical documents, notes, and previous decision.
            5. Upload additional documents that you receive from the provider.
            6. In the Clinical Review section:
              1. Indicate the status of the clinical documentation and clinical guidelines based on your review.
              2. Select the approved level of care.
              3. Specify the approved quantity of each service or diagnosis code. Based on the requested and approved quantity, the decision for each item is auto-populated to Approved, Denied, or Partially Approved.
            7. In the Review Decision section, specify your decision on the request, the reason, and any notes or comments.
            8. When you’re done, click Submit.
             
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