Utilization Management and Bill Screening – Workforce Alabama

Utilization Review

Utilization review is necessary to determine the medical necessity for medical and surgical in-hospital, outpatient and alternative setting treatments for acute and rehabilitation care. It includes pre-certification for elective treatments. Concurrent review and retrospective review, if necessary, are required for emergency cases.

Bill Screening

Bill screening is the review of provider bills to ensure reimbursement is appropriate and consistent with medical necessity and established payment guidelines. This process includes identifying duplicate or unbundled charges, confirming that services are related to the reported injury or illness, assessing the need for assistant surgeons, reviewing multiple or global procedures, evaluating the number of modalities billed and addressing other applicable reimbursement issues.

Implementation

Utilization management and bill screening may be implemented, but it is not required. Though, it must be performed by qualified individuals or entities, according to Code of Alabama, 1975, §25-5-293(g).

Any self-insured employer, self-insured group fund, or insurance carrier that does not choose to perform these services is requested to advise the Workers’ Compensation Division in writing.

Each self-insured employer, group fund, insurance carrier or utilization review company that will perform these services can download the application for certification.