Deerwalk Blog

Utilization Management in Everest - Part 2

Posted by Shrijana Tandukar on October 05, 2012

This is part 2 of a two part article on how Utilization Management (UM) works in Everest. (You can read part 1 here.) Part 2 covers inner workings of the UM module.

In Everest, nurses can document all activities related to an authorization using the following forms:

  1. Authorization Request: In the request form, the clinical user enters demographic information related to the request for an authorization such as level of urgency, diagnosis, date of patient’s admission/start date of services, anticipated discharge/end date, place of service, planned procedure and information about the providers. The authorizations have “Attach Documents” functionality allowing the nurses to attach documents provided by providers, facilities, members, and others related to the authorization request.
  2. Extension Request: When additional inpatient days, services or drugs are needed past those initially authorized, an Extension Request is completed. This form includes the date and time of request, the number of requested days/services, the type of request, the level of care needed and the reason for the extension request. An authorization may have one or more extension requests.
  3. Review: The Review section of an authorization is intended for use when a clinical review is necessary. The details of the review are captured in this form. Key pieces of information such as the review type, review date, criteria used for review, review status, and the review outcome can be captured. The reviewer can attach documents from sources outside of Everest related to the review. There may be one or more reviews done during the life of an authorization.
  4. Consultant Review: The Consultant Review section of an authorization is intended for use when a physician review is necessary. The consultant review form supports all levels of review activity. It captures information such as date the review was done, review type, status of the review, information reviewed, and reviewer recommendations. There may be one or more consultant reviews done during the life of a given authorization.
  5. Discharge Info: This form is designed to capture information related to the member’s status and needs at the time of an inpatient discharge. Key information such as the discharge date, discharge disposition, discharge diagnosis and scheduled post-discharge follow-up is collected.
  6. Decisions: The Decision section of an authorization is where authorization determinations are recorded. The authorization can be approved, denied, partially authorized or suspended through the decision page.  There may be one or more determinations for an authorization. Deerwalk transmits authorization determination information to our client’s claim administrators on a daily basis.

Generating letters is one of the important features of Utilization Management. When the user clicks the ‘Generate letter’ button for a party they wish to notify of a decision, the letter template appears to the user. Letter templates are client specific and the letter presented to the user will depend on the determination / decision status. Whether or not a letter allows the user to add, delete or edit it will depend on the business rule associated with the specific template. Once the letter has been completed, the user can choose to ‘Preview Letter’ or to ‘Generate Letter’. ‘Previewing’ the letter allows the user to check it for accuracy of the entered information before actually generating it. To edit the letter, the user can cancel out of the preview letter view and be returned to the form where changes can be made to the letter. ‘Generating’ the letter closes it for further editing and saves the letter in the system.

So, in summary, the Everest Utilization Management module supports:

  • Guided flow through the complexities of the utilization management process
  • Improved coordination of care due to integration of UM into a member centric record used by all care management disciplines
  • Ease of documentation, capturing those elements to meet state and federal regulations
  • Reporting on utilization management activities
  • Ability to integrate with commercial criteria bases our clients are licensed for such as InterQual
  • Sharing of authorization information with claim payment administrators, leading to decreased errors in claims payment and time spent researching authorization details.

[Thanks to Jo Anne Hunt and Minesh Maharjan for contributing to this article.]

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