1. Prospective review

Occurs before the services are rendered.

• If the payer requires preauthorization, the request would trigger a prospective utilization review.

• A preadmission case manager should review scheduled surgical cases to determine appropriate level of care and ensure that there are no pre-op days not meeting medical necessity.

• Review National Coverage Determination to assure that the documentation in the record demonstrates that specific procedures are appropriate.

2. Concurrent review

Occurs while services are being rendered.

• If a provider requests hospital days beyond those approved, a concurrent review would be triggered.

• Medicare expects that case managers manage the medical necessity of its beneficiaries.

• DRG reimbursed cases should be reviewed for medical necessity.

• Episodes of care covered under a bundled payment arrangement should be reviewed.

• Case managers should conduct a review of all concurrent denials.

• Cases of unfunded and underfunded patients should be reviewed concurrently.

3. Retrospective review

Occurs after services have been rendered.

• Case managers should review cases when a short stay patient is admitted and discharged before a medical necessity review has been conducted.

• A denial is issued after a patient has been discharged.

Source: Case Management Concepts