Clinically driven, rule-based tools contain characteristics that serve to protect patients. For example, criteria help providers recognize the circumstances in which it is safer and more cost-effective for a patient to be cared for by a specialist. Support criteria can also aid providers in ambiguous clinical situations. An example is an anxious patient with heart palpitations who might require fewer services in the long run if he or she has been reassured by a cardiologist that there is no underlying pathology. Second, criteria are rule-based to generate consistent application by users.
Criteria represent a consensus on the best clinical practices.
They are developed after an exhaustive literature review and input from hundreds of physicians. Third, they are written to eliminate subjective clinical judgments. Without these characteristics, the result can be inconsistent decision making at best and undesirable outcomes at worst. When criteria have been satisfied at a first-level review, approval is automatic and is given without further delay. Often a case goes forward when the physician provides additional information showing that the criteria have been met.