Utilization Review Requirements. Provider shall comply with applicable utilization review requirements set forth in the Massachusetts Code and Regulations, and to the extent necessary, obtain and maintain a utilization review license in the Commonwealth of Massachusetts.
Utilization Review Requirements. You must follow the requirements of Utilization Review, which are Pre-Admission Review, Pre-Service Approval for certain outpatient services, Concurrent Review and Discharge Planning, and Individual Case Management. If you need non-emergency or non-maternity hospitalization, you or someone on your behalf must call the number on your ID card for pre-approval. Information concerning Utilization Review is detailed in your benefit description and riders. If you do not notify Blue Cross Blue Shield and receive pre-approval, your benefits may be reduced or denied.
Utilization Review Requirements. The stages of utilization review are pre-service review, care coordination review, and retrospective review. — All scheduled, non-Emergency inpatient Hospital Stays and Residential Treatment Center admissions. Exceptions: Pre-service review is not required for inpatient Hospital Stays for the following services • Maternity care of 48 hours less following a normal delivery or 96 hours or less following a cesarean section, and • Mastectomy and lymph node dissection. — Specific non-Emergency outpatient services, including diagnostic treatment and other services. — Specific outpatient surgeries performed in an outpatient facility of a doctor’s office.
