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CONCURRENT REVIEW
1. Concurrent Review is the process of continual reassessment of the medical necessity and
appropriateness of acute inpatient care during a hospital admission in order to ensure Covered Services are
being provided at the appropriate level of care. These reviews are conducted telephonically. Bravo Health
is responsible for final authorization.
2. The Concurrent Review process is performed telephonically by a licensed nurse. The Bravo Health
nurse confers with the attending Provider or other hospital staff (Case Managers, Social Workers, Discharge
Planners, etc.) regarding the acute stay and any discharge planning needs; and where appropriate, speaking
with the patient and/or family.
3. A Medical Director reviews any in-patient days that do not meet medical necessity criteria and issues a
determination. All days which do not meet medical necessity criteria, are discussed with the facility
utilization staff and attending Provider and/or PCP when appropriate or available. In those instances where
the admitting Provider does not agree with the determination, the attending is encouraged to contact Bravo
Health’s Medical Director to discuss the appropriateness of the continued hospitalization. The Medical
Director then makes a determination to approve or deny the admission or days in question.
The Hospital’s Utilization Review Department will be notified via facsimile of the daily log and/or verbally
regarding the status of the case and all denials. All determinations to deny or down grade a stay will be
followed up with a formal letter. Only a Medical Director is authorized to deny or downgrade days during
an acute stay.
RETROSPECTIVE REVIEW
Retrospective reviews are performed on all admissions to non-Participating facilities where the Member has
been admitted and discharged prior to Bravo Health’s notification. What about Participating facilities?
a. Bravo Health allows 14 days after notification for facility to provide a verbal, written or facsimile
clinical review. Bravo Health will issue a determination within 14 days of the notification based on
the clinical information provided Clinical information submitted is reviewed according to criteria
for medical necessity, and are subject to Member eligibility at the time services are rendered.
b. Retrospective review may occur for pre-authorized services in order to facilitate claims payment.
Referrals to Non-Contracted Providers
Referrals to non-Contracting Providers are approved only when the non-Contracting Providers provide
services that are not available within the network. All referrals to non-Contracting Providers must be
reviewed and authorized by Bravo Health before services are performed. There must be verification
that the Provider of service is Medicare certified. The Medical Director must review all referrals to
non-Contracted Providers. The Director of Health Services may approve non-Contracting Providers
when deemed necessary by the Medical Director.
Ambulatory Services
a. The PCP is responsible for obtaining pre-authorization for services requiring pre-authorization and
for any referral m
ade out of network.
