Continued Care: Utilization Reviews & Authorizations

Utilization Reviews & Authorizations involve ongoing assessments to determine the medical necessity and appropriateness of a patient’s care. These reviews require direct communication with insurance companies to secure authorization for treatment at the appropriate level of care. They help optimize patient care, ensure proper resource utilization, manage costs, and align treatment plans with insurance approvals. Typically, a UR nurse, biller, or clinical director conducts these reviews.

Required Permission: Users with the Super Admin or Utilization Review Internal roles can add and manage patient authorizations. Additionally, insurance company representatives with the Utilization Review External role can review the chart's content pertinent to the insurance case(s) when given the required permissions. Click here to learn more about user permissions.

Best Practice Workflow

Let's review the Kipu EMR's best practice workflow to complete utilization reviews and authorizations.

1. Filter the landing page by selecting Review in the right-hand column.

   • Filter by Date Range.
   • Alternatively, use the review Today, Tomorrow, or Past Due filter.

2. Select the appropriate patient’s chart.

3. In the Information tab, review the insurance documentation since the last approval.

   Best Practices: Documentation is essential when advocating for a patient’s care, as the insurance case manager interview helps align approvals with the patient’s needs. PDF packages compile clinical and medical documentation for a specific date range, while the Golden Thread list view pulls documentation directly related to the patient’s treatment plan. The Chart Summary tab provides a comprehensive review of documentation for a selected timeframe. Some facilities may require Utilization Review forms, though others prefer to keep these separate from the patient’s medical record. Additionally, treatment team review meetings can be used to discuss patient status, upcoming reviews, and documentation. For efficiency, these meetings should be documented directly in the patient’s chart or as a non-billable group.

4. Call the insurance case manager to request authorization and ensure continuous care at the appropriate level of care.

5. In the information tab, click +Add LOC Review to enter the outcome of the review, including the number of days authorized, level of care, start and end dates, authorization number, next review date, and status. Click here to learn more about transitioning levels of care. 

   • Best Practices: Use the New status immediately after creating a utilization review to indicate it is in draft and not yet submitted. Change the status to Pending once the review is formally submitted for approval, and update it to Approved or Denied only after receiving formal authorization or rejection, respectively. Create a new utilization review when the patient receives a new authorization number, a new Level of Care is authorized, an existing Level of Care is extended with a new authorization number, or the patient transitions between Levels of Care (e.g., Residential to Detox). Update an existing utilization review instead when the authorization is extended without a change in authorization number or when its status is updated (e.g., from New to Pending or from Pending to Approved/Denied).

6. Once you enter all the required fields, click Save Authorization.
7. The system will display the most recent utilization review by chronological order.

Best Practice: Use the Notifications feature to alert designated users of insurance-related updates, including insurance added, insurance authorization added, insurance authorization review date, insurance authorization status changed, and insurance details changed. Following these steps ensures proper documentation, timely insurance approvals, and continuous patient care management.

Integrated Billing: Users with Integrated Billing (Kipu RCM) have separate requirements for adding Utilization Reviews to ensure the required information transmits to the integrated billing software as intended. Learn more about instructions for utilization reviews through Collaborate MD and Kipu RCM.