Ambulatory Pre-certification Review
Our URAC accredited Ambulatory Pre-certification Review Program is designed to assure that these ambulatory procedures are certified as being medically appropriate to the patient’s clinical condition and are being performed at the appropriate level of care.
WHAT IT IS:
A program that reduces unnecessary ambulatory procedures (e.g., surgical procedures, lab work, MRIs, CAT scans) by recommending that only medically necessary procedures be certified.
If the procedure is certified, verifies whether the place of services is appropriate (i.e., ambulatory surgery units vs. physician office).
HOW IT WORKS:
The patient or his/her physician calls NYCHSRO/MedReview and outlines the diagnosis, proposed course of treatment, anticipated procedures, date of treatment and setting in which the procedures will be done.
This information is evaluated against nationally recognized criteria and the claims payers’ benefit allowances. After clinical review by professional nurses and/or qualified physicians, a determination is made as to whether or not the procedure is medically justified and appropriate notification is given to the patient and provider. If the procedure is assessed as being medically appropriate but the setting is not, an alternate setting is recommended.
Written confirmation of the determination is forwarded to the patient, the attending physician and the hospital, in accordance with nationally recognized standards.
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