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Amnesicat

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  1. Utilization Review outpatient authorization questions

    Amnesicat posted a topic in Case Management
    Hi, everyone. I'm a Utilization Review nurse who works in a hospital, mostly using Interqual. I do a lot of BCBS reviews and Medicaids. I'm wondering how things work on the outpatient side. Do you still use IQ criteria or is it different? What about for getting authorizations for outpatient medical equipment? For example: Say I had a patient with CP and epilepsy who needed a CPT vest and a medical grade sat monitor for home use? Is there a set of criteria to follow to get that approved or is the process completely different? For BCBS, do you still use Jiva or is it more like a commercial review? I'm just curious what it's like on the other side of things and would love to learn more!

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