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Chronic Care / Rehabilitation Review
Utilization management programs (UMP) assess the quality, medical necessity, appropriateness of setting, an timeliness of health care services provided in Massachusetts' MassHealth inpatient, chronic care/rehabilitation hospitals. They can produce significant benefits for patients, providers, and payers, including improvements in the appropriateness and quality of the care provided, the appropriateness of the setting in which members receive care, and resource utilization. Through consistent application of the most up-to-date standards of care, UMPs can identify opportunities for process improvement, detect provider education needs, and assess health care services.
Registered nurses perform initial screenings, while board certified, actively practicing, licensed physicians review cases within their specialty areas. Reviewers utilize current practice standards and defined specifications to analyze the utilization of services in order to determine the clinical basis for service delivery, evaluate the timeliness, effectiveness, and quality of the services provided, and the appropriateness of the setting in services were delivered. When indicated, alternative care options and settings can be identified.
Masspro notifies the provider when a case is denied, and the provider may request a second review by Masspro. Second-level reviews are conducted by a physician of the appropriate specialty.
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