Concurrent review

Concurrent review is the review of a continued inpatient stay to determine medical necessity, quality of care and appropriateness of the level of care being provided. Concurrent review ensures appropriate, efficient and effective utilization of medical resources.

When approving inpatient admissions, an approved number of days are assigned, and the last covered date is set. If a facility does not request an extension, by submitting necessary clinical information, there is no further review. If the patient remains hospitalized beyond the approved number of days, a provider penalty will be applied to the additional days.

Retrospective review

Retrospective review is conducted when a certain procedure or service requires a medical necessity review but was not previously authorized.