Utilization Management

Ensure care is appropriate, cost-effective and medically necessary.

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Conduent’s URAC-accredited utilization management services are seamlessly integrated with case management, bill review and medication management to deliver greater care and medical savings.

Utilization Review

Utilization review (UR) is the process used by employers and claims administrators to determine if a proposed treatment requested for an injured worker is medically necessary. In some states, UR programs are required by law.

UR requests for authorization (RFA) are coordinated by Conduent nurses with oversight by our national medical director. Decisions whether or not to approve a medical treatment recommended by a treating physician are based on state-mandated or evidence-based medical guidelines, including the American College of Occupation and Environmental Medicine (ACOEM) and ODG®.

We offer multiple levels of UR:

  • Prospective review – UR conducted prior to the delivery of the requested medical service
  • Concurrent review – UR conducted on an RFA submitted for treatment during an inpatient hospital stay
  • Retrospective review – UR conducted after medical services have been provided and for which authorization has not already been given
  • Expedited review – UR conducted when the injured worker faces an imminent and serious threat

Clinical Peer Review

A peer review involves an extensive review of the requester’s questions, associated medical records and other clinical information. Special focus is given to pre-existing conditions, compensability, causality, and other relevant factors. Conduent delivers reliable decisions that are consistent with relevant standards of care and free of conflicts of interest.

Our services include:

  • Initial and appeal certifications
  • Complex medical records file reviews
  • Critical disability and return-to-work consults
  • Impairment ratings
  • Physician peer-to-peer

Drug Utilization Review

Our DUR clinicians combine advanced polypharmacy expertise and data assessments  to help you tackle challenges with drug abuse, misuse and overutilization — the leading driver of claim costs, claim duration and patient risk.

Available services include:

  • Synchronized patient management
  • Formulary review and management
  • Formal drug approval process
  • Chronic medication protocols