The process to be certified in some states is overwhelming and costly. I authored an extensive document and completed lengthy questionnaires just to be considered for certification. Here's a list of those states requiring certification - Alabama, Arkansas, Arizona, Connecticut, Georgia, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Minnesota, Mississippi, Missouri, Nevada, New Hampshire, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Virginia, North Carolina. There may be a few more, since rules and regulations are changing monthly. One more thing.
Many states require the file being reviewed to be discipline-matched, ie.
Prior to this, denials often came from a computer software program, nurse case manager, claims adjuster, or most concerning, from a reviewing clinician who was unqualified. I believe these are some essential components to a fair and reasonable UR process. The review must always be discipline -matched. When prospective or concurrent reviews are performed, determination to recommend additional treatment should begin from the date of the review, eliminating any retrospective component. In every instance and without exception, the reviewing clinician must be prepared to speak directly the treating doctor to discuss issues of concern, and this includes the appeal process.