KY Group Health UR Process

The purpose of pre-admission, admission, or re-admission review is to determine the medical necessity of the services, performed on an elective basis, to be provided, and the appropriateness of the proposed setting. Medical Review, Inc. (“MediReview”) shall base review decisions in accordance with generally accepted standards of medical practice; and clinically appropriate in terms of type, frequency, extent and duration. MediReview shall ensure consistent application of review criteria via monthly review of utilization review (“UR”) decisions by the medical director.

Initial reviewers may issue approvals based upon approved criteria. If unable to approve, the request shall be referred to a licensed physician. The licensed physician can approve or deny the health care service. He/she will utilize criteria; however, the licensed physician shall also give his/her best medical opinion based upon submitted medical fact and allow the treating provider to provide additional information.