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| Medical Review Criteria Guidelines for Managing Care, 6th edition |
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| Description |
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| An important 2-volume resource to improve care and cost-savings for utilization management and claims departments. 1,130 pages include more than 1,500 detailed clinical review criteria guidelines listing specific indications for medically necessary ambulatory care or inpatient tests and procedures. Extensive references follow each guideline. Resources include LOS benchmarks by DRG for Medicare, commercial and Medicaid populations. Outpatient procedure list. "The Bible" for HMO benefit interpretation guidelines. This is a critical comprehensive resource for clinical review determinations. Updated continuously as new information from authoritative resources becomes available.
This is the most comprehensive review criteria guideline resource available.
Table of Contents
- Introduction
- Allergy Testing and Desensitization
- Anesthesiology/Pain Medicine
- Complementary and Alternative Medicine (CAM)
- Blood Bank
- Cardiology
- Cardiovascular/Peripheral Vascular Surgery
- Dermatology
- Disposable Medical Supplies/Durable Medical Equipment
- Educational materials
- Emergency medical services
- ENT, Oral Surgery and Dental Services
- Gastroenterology
- General Surgery
- Hematology/Medical Oncology
- Laboratory
- Miscellaneous
- Nephrology
- Neurology/Neurosurgical
- Nuclear Medicine
- Nutritional
- Obstetrics/Gynecology
- Ophthalmology
- Pediatric
- Pharmacy
- Plastic Surgery
- Pulmonary
- Radiology
- Radiology Benefit Management
- Radiation Therapy/Oncology
- Skeletal-muscular system
- Urology
- Vascular Laboratory
- Addenda
- References and Resources
- Note
Note: Review criteria guidelines or ‘benefit interps’ are useful resources for claims payment decisions to base medical necessity decisions, particularly when little or no preauthorization function or information exists as well as utilization management, educational and precertification tools. They should be distributed to relevant physicians and other providers for review, input and any needed change prior to implementation. All should be reviewed and approved by a Medical Policy Committee of the purchasing organization prior to use. Modification related to local clinical circumstances or terms of applicable certificates of coverage or provider contracts may be appropriate and necessary.
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Publication Date: January 2007
Number of Pages: 1130
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