Utilization Review study kit
Cheatsheet, term cards, never-miss list, and a seven-day plan. Original study material.
The rule
Approve when written criteria are met. Refer coverage doubt. Do not issue the denial.
If the finding is not documented, write that it is absent and pend or refer.
Never miss
- Prospective, concurrent, and retrospective packets differ.
- Criteria products are named as concepts only.
- A scheduling comment is not clinical evidence.
- Peer-to-peer needs the packet, the question, and the treating clinician.
- The physician or other qualified practitioner decides inpatient versus outpatient. The desk reviewer does not.
- A status packet starts with the order for inpatient admission.
- When later entries conflict with the order, quote them with author and time. Name the order as the anchor. Do not strip the losing version.
- A committee send is the question in one sentence, every document you read with source and date, and only the pages the question turns on.
Traps
- Putting a nurse's name on a denial.
- Assuming a finding because the stay is long.
- Skipping the note when the portal is slow.
- Letting the payer contact or the review committee decide admission status.
- Sending every historical volume so the committee never has to request more.
Shortcuts
- Today's update for concurrent review.
- Physician reviewer for doubt.
- Keep the trail.
Memory hooks
- APPROVE-OR-REFER. The only two nurse moves UM scope.
This is a practice drill for the desk.
- Day 1Scope and safe next stepRead the Scope and safe next step terms, then the never-miss lines that touch this domain.
- Day 2Packet and evidenceRead the Packet and evidence terms, then the never-miss lines that touch this domain.
- Day 3Routing, clocks, and follow-throughRead the Routing, clocks, and follow-through terms, then the never-miss lines that touch this domain.
- Day 4Scope and safe next stepRead the Scope and safe next step terms, then the never-miss lines that touch this domain.
- Day 5Packet and evidenceRead the Packet and evidence terms, then the never-miss lines that touch this domain.
- Day 6Mixed recallRun the term cards, then a short drill. Restate the one-line rule out loud.
- Day 7Full drillSit the 9-question exam and review every miss against this kit.