CMO's Utilization Management Services are designed to review utilization with a particular focus on detecting under- and over-utilization of services through a variety of control and oversight mechanisms. Chiefly, CMO fosters and supports the Primary Care Physician and works to establish a referral process that ensures appropriateness while preserving access.

Determining Benefit Coverage and Medical Necessity
CMO uses a host of information management solutions to make decisions regarding benefit coverage and medical necessity, including the member's certificate of coverage, review of State and Federal regulatory requirements, collection and review of clinical information provided by the PCP and/or specialist, inpatient and outpatient medical chart review, physician peer-to-peer discussion, and comparison to clinical decision support criteria used by Case Management and Behavioral Health as part of the utilization review process.

Preauthorization
When a health plan requires that certain services be preauthorized, CMO conducts a prospective review to determine member eligibility, benefit coverage and medical necessity, and appropriateness of selected services. During this process, assessment of case management is conducted and referrals to case management are initiated as appropriate.

Elective Inpatient Admission Review
Elective admissions that require notification are handled by CMO quickly and efficiently. Review is conducted under the direction of Licensed Registered Nurses and physicians to assess the appropriateness of the inpatient level of care. Referral to case management is initiated if appropriate.

Emergency Care and Admission Review
CMO has extensive experience in reviewing admissions that result from a member seeking immediate treatment at an emergency facility. CMO's staff obtains clinical information from the attending physician and conducts a review of the appropriateness of the admission. If the patient has been discharged, the Case Management staff will perform a retrospective review.

Continued Stay Review
CMO conducts a Continued Stay Review on all inpatient admissions to assess the need for ongoing inpatient treatment in a hospital or extended care facility.

Readmission Review
Physician-directed reviews are conducted on all inpatient readmissions. Through the Readmission Review process, discharge planning is assessed, communication with PCP's and treating MD's is performed, and patients are referred to Case Management and Disease Management specific programs.

Retrospective Review
Retrospective Review is conducted by clinical staff to evaluate the medical necessity of admissions that do not go through the authorization process, to ensure the integrity of information received during the prospective review process, to identify cases where admission may have resulted from inadequate outpatient management, and to ensure the accuracy of diagnostic coding and DRG assignment (when applicable).