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Provider Handbook
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Previous Page Table of Contents Next Page
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Prospective Review
Concurrent Review
Case Management
Discharge Planning
Retrospective Review |
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Utilization Management |
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Utilization management is a process that manages the beneficiary at the point-of-care through prospective review, concurrent review, case management, discharge planning and aftercare planning activities, and retrospective review. |
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Prospective Review |
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The patient care coordinator performs concurrent review and discharge planning. Discharge planning and case management services are automatically considered for all TRICARE beneficiaries in facilities in the South Region where Humana Military provides utilization management services. The objectives of discharge planning include:
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- Determining medical necessity
- Evaluating proposed treatment
- Assessing level of care required
- Determining appropriate level of care prior to admission
- Identifying potential for discharge planning needs and determining whether the case meets care coordination or case management criteria
- Identifying potential quality-of-care issues
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Physicians and/or peer reviewers perform second-level reviews. |
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Concurrent Review |
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Concurrent review is a process of continual reassessment of the beneficiary’s needs during an inpatient stay. Concurrent review activities monitor the patient for appropriate level of care and identify potential care coordination, disease-management/demand-management, discharge needs, and case-management candidates.
The care coordinator responsible for concurrent review evaluates the beneficiary’s level-of-care needs during hospitalization. Based on medical determinations of levels of assistance that may be required, an entire episode of medical care may be adapted to fit the beneficiary’s status and needs. Components may include:
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- A continuum of health care based on identified needs and goals
- Design and adaptation of health care initiatives for the beneficiary
- Identification of assistance needs throughout an entire episode of care
- Beneficiary and family education
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Case Management |
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Case management services are provided by Humana Military nurses for TRICARE beneficiaries with complex health needs and should be referred to Humana Military case management for an evaluation. The following conditions call for mandatory referral to case management:
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- Premature infants: Ventilatordependent more than 24 hours and/or weighing less than 1,500 grams
- All transplants, including peripheral stem cell
- Excludes corneal transplants
- Acute inpatient rehabilitation (not skilled nursing facility with physical therapy only)
- New quadriplegics and paraplegics
- New head injury
- Ventilatordependent patients
- OB patients with identified risk factors
- Requests for hourly nursing more than four hours per day
- Burn patients requiring a referral to a burn unit
- Unplanned admissions to an acute hospital three times or more within 90 days with the same diagnosis
- Complex chronic condition which results in high resource consumption
- ECHO requests
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This list is not all-inclusive and is subject to change. Any beneficiary with a complex case who may benefit from case management is eligible for an evaluation. |
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Discharge Planning |
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The patient care coordinator performs concurrent review and discharge planning. Discharge planning and case management services are automatically considered for all TRICARE beneficiaries in facilities in the South Region where Humana Military provides utilization management services. The objectives of discharge planning include:
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- Minimize inappropriate use of hospital resources.
- Evaluate acuity of the cases to project resources necessary to affect positive discharge planning.
- Identify and use cost-effective care sites when clinically appropriate.
- Prevent unnecessary admissions/avoid readmissions caused by incomplete course of treatment.
- Locate and use all alternative sources of available funding.
- Avoid either underutilization or overutilization of health care services.
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Retrospective Review |
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Retrospective review is conducted when a certain procedure or service requires a medical necessity review and authorization was not obtained prospectively. The review is performed under the direction of a registered nurse, and aspects of the retrospective review include the following:
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- Inpatient medical necessity and appropriateness of level of care
- Medical necessity of surgical and other procedures that affect diagnosis-related group (DRG) assignment
- Potential quality problems associated with premature discharge identified by first level review using InterQual® or behavioral health criteria and confirmed by physician review
- Behavioral health claims review, if present in the sample
- Discrepancies between the medical record and the claim in regard to diagnoses, procedures, and discharge status
- Discrepancies between the prospective review information and the medical record
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