Americanmso

Utilization Management

Utilization management or utilization

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Utilization management or utilization review is the use of managed care requirements for prior authorizations and hospital clinical review, which will allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing the appropriateness of the benefits against evidence-based guidelines/criteria before they are provided.

IPAs managed by Innovative Management Systems (“IMS”) will NOT be financially responsible for any services conducted without prior authorization approval.    

Utilization management or utilization review is the use of managed care requirements for prior authorizations and hospital clinical review, which will allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing the appropriateness of the benefits against evidence-based guidelines/criteria before they are provided.

IPAs managed by Innovative Management Systems (“IMS”) will NOT be financially responsible for any services conducted without prior authorization

Providers can request prior authorization through the provider portal, which can be accessed through this link: https://quickcap.imsmso.com/imsmso/general/index.php. If you do not yet have a portal account, please call IMS MSO at 323-800-8283 to obtain a copy of the Authorization Request Form and for further assistance. If you are submitting using the Authorization Request Form, please fax the form and clinical notes to the IMS UM Department at 323-798-3031.

Authorization does not guarantee payment. Patient must be eligible with the respective IPA on the date of service. Authorizations are valid for 90 days based on patient’s eligibility status. It is the responsibility of the provider to verify patient’s eligibility prior to providing services.

Post-stabilization care

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Post-stabilization care services that are administered if the hospital fails to call IMS to request pre-approval of post-stabilization care services and fails to wait 1 hour for pre-approval/authorization after the request. “Post-stabilization care services” are covered services that are related to an emergency medical condition provided after an enrollee is stabilized, and provided to maintain the stabilized condition, or under certain circumstances, to improve or resolve the enrollee’s condition.

All IPAs managed by Innovative Management Systems follow all federal Medicare regulations regarding assuming financially responsible for post-stabilization care services obtained within or outside the IPA network.

Submission of an inpatient notification is required for inpatient admission within 24 hours upon pre-approved admission. Please include the Face sheet along with any other supporting clinical documentation where applicable.

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HealthSmart MSO’s UM Department expedites request for authorizations and coordinates with the clients Medical Directors the fundamental practice of managed care. We strive to keep referrals within our clients contracted network. Physician profile referral statistics and hospital bed days reported monthly gives Our Clients a current overview of their UM activities. The Case Manager plays an important role in the monitoring, tracking and implementation of the utilization and quality of patient care process. More importantly, Case Management carefully monitors patients’ status on a daily basis. HealthSmart MSO’s IPA’s have contracted hospitalists to assist PCPs in inpatient admission, which further enhances the quality and coordination of care to our members.

[Text Wrapping Break]UM decision making is based only on appropriateness of care and service and existence of coverage. Financial rewards or incentives must not influence any utilization decisions. All denials must be strictly based on insufficient medical appropriateness or not a covered benefit. No rewards or incentives are given for issuing denials of coverage or service. To assure that the risks of under-utilization are considered, no rewards or incentives can be issued that will discourage appropriate care and services to the members.