Utilization Management - sending clinicals

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Specializes in Med - Surg.

I am new to UM, for large hospital, uses Allscripts with Interqual. My question is when I have private insurance company who requests clinicals, is it procedure to not only attach h&p, notes, etc. but to type out the info in the SI & IS boxes? Seems like extremely time consuming and "double charting" to type everything in boxes as well as attach.

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Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.

Do you have other UR/UM/CM nurses in your hospital? If so, talk to them about your hospital's policy. You may not need to use both for one submission, rather you may use one to submit to insurance companies and the other for something totally different.

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Not only are you right that it is redundant, I can assure you that no one on the payor side is going to read the Interqual junk, it has no credibility.

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I have been a UM nurse for several years on the insurance side. You don't need to send the IQC for review unless you want to. Every once in awhile a provider will print out how they applied clinicals to IQ. While it makes it nice and easy to follow their train of thought, its certainly not necessary. More often than not, providers don't send their IQ review.

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I have some experience in CM/UM but am returning after a lapse. Could you please refresh my memory on the terms: SI and IS ?? And also: IQC and IQ ???

Thanks so much!

I am new to UM, for large hospital, uses Allscripts with Interqual. My question is when I have private insurance company who requests clinicals, is it procedure to not only attach h&p, notes, etc. but to type out the info in the SI & IS boxes? Seems like extremely time consuming and "double charting" to type everything in boxes as well as attach.
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SI is the severity of illness and IS is intensity of service. IQC and IQ is sort of interchangeable. InterQual Criteria.

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