Utilization Review

Overview

Comprehensive Medical Review Services (CMRS) stands out in the industry for its exceptional utilization review capabilities, drawing on a nationwide network of credentialed, actively practicing, board-certified physicians, chiropractors, psychologists, physical and occupational therapists, and acupuncturists. Our extensive experience and rigorous standards ensure that our providers deliver high-quality determinations on medical necessity and standards of care – timely, customizable, and supported by nationally recognized evidence-based treatment guidelines such as ODG and state-specific guidelines like CA MTUS.

Our Utilization Review Process

1. Claim Referral and Verification

Upon referral of a claim by a claims examiner, case manager, or account manager, CMRS’s Utilization Review (UR) coordinator conducts a preliminary review to confirm clarity of the request, completeness of medical records, and correct assignment to an appropriate provider or specialty. The coordinator assigns the claim to the appropriate board-certified specialist and determines if additional information is necessary for a comprehensive review.

2. Detailed Medical Review

The assigned reviewing physician thoroughly reviews the medical records, prepares a detailed summary, and formulates clinical recommendations based on state-appropriate, evidence-based treatment guidelines. The reviewing physician typically attempts a minimum of two peer-to-peer outreach efforts to discuss the request with the treating physician. CMRS staff assist in coordinating schedules for these discussions. The objective is to reach a professional consensus on the requested treatment or diagnostic study.

3. Quality Assurance and Reporting

Upon completion, the report is uploaded into CMRS’s system and undergoes a thorough review by our experienced QA team, which ensures each report includes all necessary information, clear recommendations, and citations from state-appropriate guidelines. The report format is customized to meet each client’s specific needs. Our team collaborates with the reviewing physician to ensure 100% accuracy and timely turnaround, with same-day rush capability when necessary.

Why Choose CMRS for UR

• Industry-leading contact rates – dedicated scheduling support drives peer-to-peer success
• Exceptionally low appeal rates – driven by defensible, evidence-based determinations
• Customized reporting – format and scope adapted to each client’s requirements
• HIPAA and URAC compliant – all PHI fully secured
• 99%+ on-time TAT – means zero delays in your claim decisions
• Same-day & Next-day rush availability – when urgency demands it