Utilization Review And Case Management Services Assisting You With Your Decisions About Health Care
Contact your Insurer or read you Health Insurance Card to find out if Moody Review, Inc. provides Utilization Review and Case Management Services for you. The Utilization Review and Case Management staff at Moody Review, Inc. is made up of physicians, registered nurses and support staff whose priority is to assure that you and your family members receive the appropriate and best quality health care possible, based on established standards. They may even be able to reduce the total amount of your health care costs and in some instances, may be able to help you avoid unnecessary surgery and/or extended hospital stays.
We are here to assist you with you questions about health care and hospitalization:
1. What is Pre-Certification?
Pre-Certification is the process of determining the appropriate level of patient care necessary according to the severity of the illness or injury.
2. When do I need to obtain Pre-Certification?
When you or any member of your family covered on your policy require any of the services requiring pre-certification listed in your member hand book or plan document provided by your insurer. You should contact your insurer to obtain a plan document or member handbook if you do not have one.
When it is determined that any of the services requiring pre-certification are to be scheduled, please contact Moody Review, Inc. at 1-800-293-1397. We will ask several basic questions to obtain information regarding the diagnosis, demographics, the name of your physician, the physicians phone number, and the date and place of admission. We will also assist you with any questions or concerns you may have.
The nurse will contact the physician to obtain medical information about your condition, which is necessary to complete the process of pre-certification. If the service criteria are met, the attending physician or the hospital will be notified by phone of the certification number for their records. Written confirmation will be mailed to you within 48 hours.
3. What happens if I receive services and do not obtain the required Pre-Certification?
If you receive services that require pre-certification and you do not obtain the required pre-certification, this may result in a reduction of benefits for that service.
Contact your insurer to find out which services require pre-certification or consult your plan document or member handbook.
4. When is a second surgical opinion needed?
Second surgical opinions may be required to ensure the necessity of a recommended elective surgery. During the pre-certification process a decision will be made if a second surgical opinion is needed. If a second opinion is necessary, you will be contacted by a Moody Review nurse to make the arrangements.
5. What if my doctor wants me to remain in the hospital longer than originally anticipated?
If you require additional inpatient treatment, past the anticipated date of discharge, the Review Nurse will contact your attending physician to obtain more medical information using the same criteria as the pre-admission review. This information will enable the nurse to determine if additional days are needed.
6. What if my doctor disagrees with Moody Review's recommendation?
You and your physician have the right to appeal the decision by contacting us at the Pre-certification phone number below. At Moody Review, the Medical Director reviews the available information and is available to speak to your physician. Within 30 days a decision is made. In all instances, you and your physician make the final decision concerning treatment.
7. What is Case Management?
Case Management is a collaborative process between the Case Manager, the patient and family, and the other health care professionals involved in a patient's care. Through detailed assessment and planning a Case Manager implements and coordinates a plan that facilitates a patient's access to the most appropriate and cost effective services. With continued collaboration, monitoring, and evaluation, the plan is modified to meet the changing needs of the patient until the episode of care is complete. At Moody Review, Inc. Case Management services are provided to patients with complex needs upon referral by the Insurer.
To Obtain Pre-Certification
A patient, family member or provider may contact a Utilization Review Nurse at Moody Review, Inc. at: 1-800-293-1397
You may also page a Utilization Review Nurse at: 1-888-913-1707
Authorization or certification by Moody Review, Inc. does not guarantee payment. Payment is subject to eligibility and may be affected by such things as limitations in the benefit plan covering you and your dependents and any pre-existing condition limitations. Terms of coverage can be verified through your insurance carrier by calling one of the telephone numbers shown on your I.D. Card.
