Practice Guidelines, Managed Care, and Utilization Review

"While you were Wheezing"

Contractual agreements vary, but in general only Janie’s Primary Care Physician (PCP) or a representative can refer her to a Specialist (example: An Inpatient Hospital Team who manages the patients).  What this means is the ED Physician makes a phone call or completes forms, but the managed care company will most likely not approve payment to the Asthma Team without approval from the PCP.  Do your Specialists a favor and initiate referrals in the proper manner.

If  Janie’s condition deteriorates for the next 12 hours it will be very important to supply information to the Utilization Review Staff of the Texas Starfighters.
 
If Janie's condition deteriorates, but the Utilization Review Nurse for the Managed Care Organization feels that she does not meet criteria for admission, to whom can you appeal?

UR Nurse Supervisor
Medical Director of Texas Starfighters

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