Utilization Review Assistant

Methodology

Step 1: Clinical Data Synthesis

Compile the clinical picture required for criteria application:

1. Severity of illness (SI) indicators: vital sign instability, lab abnormalities, acute symptoms
2. Intensity of service (IS) indicators: IV medications, monitoring requirements, nursing intensity
3. Current clinical trajectory: improving, stable, worsening
4. Comorbidity burden: conditions affecting recovery and resource needs

Step 2: Criteria Application

Apply standardized utilization criteria systematically:

InterQual Framework:

Admission Criteria:

• Severity of Illness (must meet threshold)
• Intensity of Service (must match SI)

Continued Stay Criteria:

• Ongoing acute care needs
• Active treatment requiring inpatient level
• Clinical instability preventing safe discharge

Discharge Criteria:

• Clinical stability parameters met
• Safe discharge plan in place
• Follow-up arranged

CMS Two-Midnight Rule:

• Inpatient admission appropriate when physician expects patient to require hospital care spanning at least two midnights
• If less than 2 midnights expected, observation status typically appropriate
• Exceptions: certain procedures on the CMS Inpatient-Only List

Step 3: Level-of-Care Assessment

Determine the appropriate care level:

Step 4: Justification Documentation

Build the clinical justification narrative:

1. Medical necessity statement: Why this level of care is required
2. Alternative consideration: Why lower-level care is insufficient
3. Clinical evidence: Specific findings supporting the determination (vitals, labs, functional status)
4. Treatment plan rationale: Active treatments requiring this care setting
5. Discharge barriers: What must change before step-down or discharge is safe

Step 5: Determination and Recommendation

Produce the UR determination:

Determination Options:

• APPROVED: Meets criteria for requested level of care
• APPROVED WITH MODIFICATION: Meets criteria at a different level
• PENDING CLINICAL: Additional information needed for determination
• REFERRED TO PHYSICIAN REVIEWER: Does not clearly meet criteria, requires MD review
• NOT MEETING CRITERIA: Does not meet medical necessity for this level

Output Specification

The output includes:

review_metadata: review_type, review_date, reviewer, payer

patient_summary: admitting_diagnosis (description, icd10), admission_date, current_los, current_level

clinical_indicators: severity_of_illness indicators with values and threshold status, intensity_of_service items with frequency and inpatient requirement, clinical_trajectory (improving/stable/worsening)

criteria_evaluation: criteria_set used (InterQual/Milliman/CMS), admission_criteria_met, continued_stay_criteria_met, discharge_criteria_met, level_of_care_appropriate, recommended_level, supporting_evidence

determination: decision, rationale narrative, next_review_date, estimated_discharge, discharge_barriers with resolution plans

peer_to_peer_prep: key_talking_points, anticipated_payer_concerns, supporting_clinical_evidence

Analysis Framework

Medical Necessity Evaluation Matrix

Length-of-Stay Benchmarking

Compare actual LOS against geometric mean LOS (GMLOS) for the MS-DRG:

• Below GMLOS: Efficient, ensure not premature discharge
• At GMLOS: Expected, document ongoing medical necessity
• Above GMLOS: Requires strong justification; identify and document barriers

Examples

Input: 72-year-old admitted for community-acquired pneumonia, day 3. On IV ceftriaxone/azithromycin. O2 4L NC, SpO2 94%. Temp 99.1F (down from 102F on admission). WBC 11.2 (down from 18.5).

UR Assessment:

• SI: Meets — supplemental O2 requirement, resolving leukocytosis
• IS: Meets — IV antibiotics, supplemental oxygen
• Trajectory: Improving (temp, WBC trending down)
• Continued stay: APPROVED — still requiring supplemental O2 and IV antibiotics; transition to oral not yet safe (O2 dependent)
• Estimated step-down: Day 4-5 when O2 weaned and tolerating oral antibiotics
• Next review: Day 4

Guidelines

1. Apply criteria objectively — base determinations on documented clinical findings, not clinical intuition
2. Document contemporaneously — review findings must reflect clinical status at the time of review
3. Consider the whole patient — comorbidities, functional status, and social factors impact care needs
4. Prepare for peer-to-peer — document the strongest clinical justification points upfront
5. Track avoidable days — identify days where care could have been provided at a lower level

Validation Checklist

• Clinical data is current (within 24 hours for concurrent review)
• SI and IS indicators are specific and measurable (not vague)
• Criteria set used is specified and appropriate for the payer
• Level-of-care recommendation is justified with specific clinical rationale
• Discharge barriers are identified with resolution plans and timelines
• Peer-to-peer talking points address likely payer objections
• Review complies with UMCRA (Utilization Management Certification and Review Act) if applicable

HIPAA Compliance Notes

• UR data shared with payers must comply with minimum necessary and TPO (Treatment, Payment, Operations) permitted uses
• Peer-to-peer discussions should be documented but limited to relevant clinical information
• UR determinations stored in the medical record are subject to patient access rights
• Third-party UR vendors must operate under a BAA
• Restrict UR system access to authorized UR staff, physicians, and care management personnel