Utilization Review

High-quality service

Utilization Review that supports appropriate care and delivers real savings. With CareWorks Managed Care Solutions Utilization Review, you know your injured workers are receiving the appropriate treatment for their injury at every step during their recovery.

Our utilization review experts accurately and efficiently assess the medical necessity of prospective, concurrent and retrospective services using evidence-based medical guidelines. Injured workers gain fast access to care that’s appropriate for their specific injury, and you avoid the expense of inappropriate or ineffective treatment.Our superior technology and nationwide network of medical experts helps get your injured workers onto the best path for recovery and back to work as quickly as possible.

CareWorks provides a national network of utilization review experts which assures state-specific jurisdictional expertise. Our utilization review processes and decisions comply with all state or local regulations, and all of our services and providers comply with stringent URAC standards.

What We Offer:
  • Our Services Include
  • Simplicity through technology
  • Decisions That Stand Up to Scrutiny

  • Prospective utilization review — assesses proposed treatments to quickly determine the medical necessity of the treatment requested and to non-certify treatment inappropriate and ineffective treatment.
  • Concurrent utilization review — assesses ongoing care and can help determine whether additional services, such as further hospital days or rehabilitation visits are medically necessary.
  • Retrospective utilization review — addresses a potential care-related issue after treatment has been rendered but before a bill has been paid. This type of review can be a key element in potential claim dispute or denial based on medical necessity.

Our proprietary CareLink software allows seamless communication across all CareWorks review systems, and can link your utilization review decisions to other services, such as assorted bill review, claim and independent medical review systems.   Clients using CareWorks’ bill review system gain even greater efficiencies through enhanced communication between CareLink and the CareWorks bill review system.    Utilization review determinations are automatically documented in the bill review system.  Additionally, advanced technology allows the bill review system to pend and refer a bill for retrospective utilization review to CareWorks.  The system connections allows this process to happen quickly and efficiently so that all regulatory are met.

CareLink’s system protocols drive consistency in the data gathered as well as the adherence to various state regulations and client special handling procedures.  Our staff work within standardized decision templates to assure we capture and document decisions in a consistent and thorough manner.   System calculated timelines drive the workflow for staff allowing them to work the cases in order of hierarchy and timeline.   Distribution of decision documentation is automated for faster delivery and better documentation.   Meaningful reporting delivers tracking, trending and transparency

CareWorks utilization review provide monthly and quarterly savings reports which summarize and detail the results in the period. These reports provide insight into what types of treatments are being requested and the outcomes of those review determinations.    Additionally, turnaround time reporting provides assurance of the timeliness of services provided.

We can also create customized reports to track any available parameters at your request.

If the time comes to question the medical necessity of a service or procedure or a utilization review decision, CareWorks clients can take confidence in our track record.

Two recent studies illustrate the success rates of CareWorks’ vigorous review progress.

In Texas, a 12-month study of 15,037 cases in 2012-2013, showed only 116 – less than 1 percent of all requests – were referred to the state’s Independent Review Organization (IRO) for dispute resolution. Of those cases, the IRO process overwhelmingly supported the initial utilization review determination for 95 – or 82% – of the cases reviewed.

In California, only about 10% of CareWorks UR determinations are sent by the provider through the Independent Medical Review (IMR) process, which is the state mandated external appeal process.  Of those decisions, CareWorks determinations are upheld in whole or in part 90% of the time.

A truly effective managed care solution

Our comprehensive array of managed care services deliver the right results for our clients and their injured workers.

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