Facets Criteria Maintenance application group

Utilization Management (UM) is a series of integrated processes that help to ensure that treatment is medically necessary as required by the member’s contract. The goal is to discourage or avoid medically unnecessary treatment. And at the same time it ensures that medically appropriate care is cost effective.  

"Clinical edits" indicates  the evaluation of billed codes in relationship to each other for the purpose of identifying unbundled procedures, surgical coding errors, invalid data relationships, patterns of utilization that deviate from practice standards, and diagnoses or procedures that may be invalid for the age and/or gender of the patient.

The Criteria Maintenance group consists of those applications that let healthcare payers set up the evaluation criteria that they need during utilization review, clinical editing, and capitation processing to make authorization decisions based on established medical criteria. This information helps claim reviewers or claims examiners to make authorization decisions based on established medical criteria. It can also help them to detect potential or actual billing issues with a provider’s claim. The group's applications are as follows:

1) AE Criteria by Diagnosis

2) AE Criteria by Procedure

3) Alternate Criteria Definition

4) Clinical Editing Criteria

5) Clinical Organ/Disease Panels

6) CPT to ICD  Conversion

7) CT/SC/DI Criteria

8) Dental Clinical Edit Criteria

9) Diagnosis Criteria M&R

10) Diagnosis Edit Criteria

11) Length of Stay by Diagnosis

12) Length of Stay by Procedure

13) Medical Admission Criteria

14) Optimal Recovery Guidelines

15) Procedure Criteria M&R

16) Procedure Edit Criteria

17) SameDay/Followup/PretreatProc

18) SSO Waiver Criteria

19) Surgical Admission Criteria

20) Surgical Indications M&R

Abbreviations:

AE stands for Adverse Event

M&R stands for Medicare and Retirement

SSO Waiver stands for Second surgical Opinion Waiver