Utilization Management and Bill Screening |
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In accordance with Code of Alabama, 1975, §25-5-293(k), the Alabama Department of Labor has filed for adoption Alabama Department of Labor Administrative Code Rules 480-5-5-.01 through .37, Utilization Management and Bill Screening. The initial effective date of these rules was September 12, 1996. A definition of Utilization Management, Utilization Review, and Bill Screening follows: Utilization Management is a comprehensive set of integrated components including: pre-certification review, admission review, continued stay review, retrospective review, discharge planning, bill screening and individual medical case management as required. Utilization Review is the determination of medical necessity for medical and surgical in-hospital, outpatient, and alternative setting treatments for acute and rehabilitation care. It includes pre-certification for elective treatments. Concurrent review and, if necessary, retrospective review are required for emergency cases. Bill Screening is the evaluation and adjudication of provider bills for appropriateness of reimbursement relative to medical necessity and prevailing rates of reimbursement, duplicate charges, unbundling of charges, relativeness of services to injury or illness, necessity of assistant surgeons, adjudication of multiple procedures, number of modalities, global procedures, and any other prevailing adjudication issues that may apply. Utilization management and bill screening may be implemented, but is not required. If utilization management and bill screening is performed, Code of Alabama, 1975, §25-5-293(g) requires such services be performed by qualified individuals or entities. Any self-insured employer, self-insured group fund, or insurance carrier that does not choose to perform utilization management and bill screening is requested to advise the Workers' Compensation Division in writing. Each self-insured employer, self-insured group fund, insurance carrier or utilization review company that will perform utilization management and bill screening can download the application for certification. |