Concurrent and Retrospective Review
- Participating Physician Groups (PPG)
Concurrent review is the process of monitoring delivery of medical services at the time the care is being rendered (inpatient admissions). Concurrent review consists of pre-admission review, continued-stay review and discharge planning.
Concurrent review is initiated at the time prior authorization is requested for an inpatient admission or on notification to the Health Net Health Services Department that a member has been admitted (in the case of an urgent or emergency admission). Concurrent review includes an evaluation of:
- Quality of care
- Plan of treatment
- Severity of illness
- Intensity of treatment
- Length of stay
- Level of care
- Discharge plan
Based on the concurrent review process, the hospital stay is approved or denied. If the stay is approved, the hospital receives a prior authorization number. The authorization number must be indicated on the hospital claim to Health Net.
All potentially non-approved services identified by the Health Net care manager (registered nurse (RN) reviewer) are reviewed with a Health Net medical director or a specialty advisor. Physicians and members have the right of appeal all un-approved services.
Retrospective review is review of the quality and necessity of medical services after care has been rendered. Retrospective professional review involves an evaluation of services that fall outside Health Net's established guidelines for coverage. These claims are reviewed by Health Net's professional review specialists (RN reviewers) and a Health Net medical director or a specialty advisor where the initial reviewer recommends that a claim be denied for lack of medical necessity.