Get DOC 311 Utilization Review - CompPharma

Pharmacists routinely perform prospective reviews in their daily practice by assessing a prescription medications dosage and directions while reviewing patient information for possible drug interactions or duplicate therapy.

(o) A utilization review decision to modify, delay, or deny a request for authorization of medical treatment shall remain effective for 12 months from the date of the decision without further action by the claims administrator with regard to any further recommendation by the same physician for the same treatment unless ...

Drug Utilization Reviews (DUR), also referred to as Drug Utilization Evaluations (DUE) or Medication Utilization Evaluations (MUE), are defined as an authorized, structured, ongoing review of healthcare provider prescribing, pharmacist dispensing, and patient use of medication.

It presents pharmacists with the opportunity to alert prescribers to potential problems and intervene in areas such as drug-drug interactions, duplicate therapy, over or underutilization and excessive or insufficient dosing.

Utilization review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary. All employers or their workers' compensation claims administrators are required by law to have a UR program.

The steps in utilization review are: The treating doctor sends a request for authorization of medical treatment to the insurance company. The insurance company sends the request to utilization review. A utilization review doctor approves, modifies, or denies the treatment request.

Health plans call for utilization management on some medicines to keep you safe, by helping to make sure the medicines you take are prescribed by your doctor and used correctly. Utilization management is made up of programs that include: Step therapy helps lower costs through safe, less expensive drugs.

What is the utilization review process? UR hospital nurse evaluates the patient and makes recommendations or seeks approval. UR hospital nurse consults with the UR insurance nurse. If the nurses disagree, physicians (or physician advisers) meet in a peer-to-peer setting to determine a course of action.