Provider Networks | Utilization Management | Component & Consultative Services

Utilization Management

Preadmission Review - Medical review of all inpatient admissions to determine medical necessity and appropriateness of services.

Concurrent Review and Discharge Planning - During hospitalization, review is done to determine ongoing medical necessity and appropriateness of care. Lengths of stays are adjusted as appropriate. The process includes the initiation of discharge planning at the time of admission and identification of cases that would benefit from case management, home health services or an alternative care setting.

Outpatient Surgery Review - Review of all surgeries performed in an outpatient surgery department of an acute care hospital or in a freestanding outpatient surgery center. Also included is medical review of all foot surgeries which involve bones, tendons or nerve reconstruction, regardless of place of service.

Point of Service/Exclusive Provider Organization Specialty Referral Authorization - Medical review of all outpatient and inpatient specialty referrals to determine medical necessity and appropriateness of services.

SSO Program - Discretionary - Plan does not have a specific list of second opinion procedures. Ohio Health Choice will review all procedures for medical necessity. If the medical indications fail to meet Ohio Health Choice's criteria, then Ohio Health Choice may request that a second opinion be obtained for any surgery. The discretionary program may be administered two ways:

1. Mandatory - If, during the process of preadmission review, Ohio Health Choice determines that a second opinion is warranted, the second opinion becomes mandatory. A benefit reduction may be issued for non-compliance.

2. Permissive - If, during the process of preadmission review, Ohio Health Choice determines that a second opinion is warranted, the second opinion will be suggested. Per benefit design, no reduction in benefits will occur if the second opinion is not obtained. However, Ohio Health Choice's determination of medical necessity may be deferred if medical indications fail to meet Ohio Health Choice's criteria and a second opinion is not obtained.

SSO Program - List - Plan has a specific list of second surgical opinion procedures. The list program may be administered three ways:

1. Mandatory - The second opinion requirement for the listed procedures cannot be waived by Ohio Health Choice (unless it is an emergency or is specifically noted for admission by contracted MDs). A benefit reduction may be issued if the second opinion is not obtained or waived.

2. Mandatory Waivable - The second opinion requirement for the listed procedures can be waived by Ohio Health Choice during preadmission review if the medical indications meet Ohio Health Choice's criteria. A benefit reduction may be issued if the second opinion requirement is not obtained or waived.

3. Permissive - The second opinion program for the listed procedures is permissive. During preadmission review, Ohio Health Choice will determine if a second opinion is warranted. If the medical indications meet Ohio Health Choice's criteria, the second opinion will be waived. If the medical indications fail to meet Ohio Health Choice’s criteria, a second opinion may be suggested. Per benefit design, no reduction in benefits will occur if the second opinion is not obtained. However, Ohio Health Choice's etermination of medical necessity may be deferred if medical indications fail to meet Ohio Health Choice's criteria and a second opinion is not obtained.

Outpatient Diagnostic Services Review - Review of the medical necessity of any or all of the following diagnostic procedures performed on an outpatient basis:
  • Computerized Tomography (CT), Magnetic Resonance Imaging (MRI) or Positron Emission Tomography (PET) scans
  • RAST, MAST, FAST, IP or Prist Testing
  • Plethysmography
  • IV Pyelography
  • Hysterosalpingography
  • Doppler Flow Echocardiography
  • Holter Monitors
  • Testing or evaluation of sleep disorders
  • Additions/changes may be made to the above list per benefit design requirements.

    Long-term Behavioral Health Review - Concurrent review of behavioral health admissions is suspended at 30 days, since most benefit programs have limits on payment for these services. For more extensive or unlimited benefit programs, concurrent review through discharge may be advisable. This service provides concurrent review through discharge for stays beyond 30 days.

    Case Management - Ohio Health Choice offers Medical and Behavioral Health Case Management Services as stand-alone service or a component of a complete managed care package.

    Ohio Health Choice provides two levels of case management:

    1. Screening - Identification, through the Utilization Review program, of those cases which might benefit from case management. Specific diagnoses, readmissions, extended stays, complex cases and use of expensive tertiary-level services are examples of case information which will be reviewed by a case manager and, if appropriate, transmitted by telephone and by report.

    2. Management - The case manager maintains contact with the patient and treatment providers to monitor and recommend appropriate, cost-effective alternatives and negotiates fees while maintaining or improving the quality of service to the patient. Reports are provided monthly, or more frequently if significant changes occur, and a Return on Investment analysis and summary is provided.


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