A physician or other health professional that holds an unrestricted license and is in the same or similar specialty as typically manages the clinical condition, procedures or treatment under review. Generally, as a peer in a similar specialty, the individual must be in the same profession, e.g., the same licensure category as the ordering provider.

A statement, which provides additional clarification of the clinical basis for a non-certification determination. The clinical rationale should relate the non-certification determination to the patient's condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.

The written screens, decision rules, clinical protocols or guidelines used by the Network as an element in the evaluation of clinical necessity and appropriateness of requested admissions, procedures and services under the auspices of the applicable health-benefit plan.

is defined as a test of the effectiveness of a therapeutic application over a period of thirty (30) days.

An oral or written expression of dissatisfaction by a member regarding a specified problem or issue without a request for a formal grievance or appeals hearing.

Utilization management conducted during a patient's hospital stay or course of treatment, sometimes called continued-stay review.

An insurer's determination that a service, treatment, drug, or device is specifically limited or excluded under the covered person's health benefit plan.

The process by which specific criteria for a healthcare practitioner are verified for use in determining the initial and ongoing approval for network participation.

The overall process of conducting a proceeding that addresses network problems and issues with individual network providers. Such a proceeding includes due process for the provider and may result in sanctions imposed on the provider by the Network.

Treatment/care requested by the patient, designed to promote optimum function.

A serious medical condition resulting from injury, sickness or mental illness which arises suddenly and requires immediate care and treatment, generally within 24 hours of onset, to avoid jeopardy to the life or health of a person as determined by a prudent lay person or as mandated by state law.

Care related to a specific diagnosis or condition for duration of time necessary to resolve the condition or reach maximum therapeutic benefit (MTB). The duration of time necessary for a patient, who re-enters the office after discharge or MTB, with a non-traumatic same or similar complaint arising out of activities of daily living (ADL), to be classified as a new episode of care, is three (3) months. All new episodes of care are required to go through the pre-certification process the same as a new patient.

A patient who has previously treated with the doctor but has not been seen in the past three months. All established patients are required to go through the pre-certification process the same as new patients.

An exacerbation is a temporary, marked deterioration of the patient's condition due to an acute flare-up of the condition being treated. Treatment of a patient, who experiences repeated exacerbations during active care, may indicate that the patient has reached maximum therapeutic benefit.

A patient that is currently being treated with a doctor and is covered under a TRIAD contract at the time the doctor is credentialed into the network. All care on "existing" patients from the time the doctor is in the network must be certified by utilizing the "Initial Care" form with all case notes and reports.

A request by telephone for additional review of a determination not to certify imminent or ongoing services requiring a review conducted by a clinical peer who was not involved in the original decision not to certify.

The institution/organization in which the requested admission, procedure or service is provided. Such facilities may include, but are not limited to, hospitals, outpatient surgical facilities, individual practitioner offices, rehabilitation centers, residential treatment centers, skilled nursing facilities, laboratories and imaging centers.

A formal written request by a member for a hearing by the Network regarding:

1. a complaint about care or services received from the Network or from a network provider, or,
2. an appeal of a decision made by the Network with regard to the provision of a requested service.

An individual who:

1. has undergone formal training in a healthcare field;
2. holds an associate or higher degree in a healthcare field, or holds a state license or state certificate in a healthcare field, and,
3. has professional experience in providing direct patient care.

a multi-disciplinary program designed to enhance and strengthen knowledge and understanding while maximizing the efficient delivery of high quality, patient-centered, outcomes-focused healthcare.

An inability to completely and/or adequately perform activities of work, play, or daily living because of loss or limitation of function.

Clinical review conducted by appropriate licensed or certified health professionals. Initial clinical review staff may approve requests for admissions; procedures and services that meet clinical review criteria, but must refer requests that do not meet clinical review criteria to peer clinical review for certification or non-certification. Sometimes referred to as "first level review."

A regimen designed to provide for the patient's continued well-being or for maintaining the optimum state of health while minimizing recurrence of the clinical status. Includes treatment procedures considered necessary to prevent the development of clinical status.

Following 4 to 8 weeks of the patient's symptoms/condition having reached a plateau, the patient will be considered at MTB.

Medically necessary care is that care that produces the best clinical outcome for the patient in the least amount of time with the lowest amount of risk. Since all medical care carries some risk to the patient, the least amount of care required to achieve this outcome is the only care that is medically necessary. Truly necessary healthcare produces efficient outcomes in an individualized and patient centric way.

A determination by a network that an admission, extension of stay or other healthcare service has been reviewed and, based on the information provided, does not meet the clinical requirements for clinical necessity, appropriateness, level of care or effectiveness under the auspices of the applicable health benefit plan.

Staff who do not meet the definition of health professional.

The National Practitioner Data Bank contains adverse licensure action reports on physician and dentists (including revocations, suspensions, reprimands, censures, probation and surrenders for quality purposes); adverse clinical privilege actions against physicians and dentists; adverse professional society membership actions against physicians and dentists; and clinical malpractice payments made on all health practitioners.

Relieves the symptoms of an exacerbation but results in no net improvement in the patient's stationary condition.

Application of treatment/care modalities by the provider to the patient, who "passively" receives care.

Information that is sufficient to allow identification of an individual patient.

Clinical review conducted by appropriate health professionals when a request for an admission, procedure or service was not approved during initial clinical review. Sometimes referred to as "second level review."

Verification by the network of a healthcare practitioner's qualifications and credentials based on evidence obtained from the issuing source of the credential.

A clinical or non-clinical statement describing the general reason(s) for the non-certification determination ("lack of clinical necessity" is not sufficient to meet this).

Refers to a healthcare practitioner's history of any pending or settled litigated malpractice suits because of the improper or negligent treatment of a patient resulting in damage or injury to the patient.

Utilization management conducted prior to a patient's admission, stay or other services or course of treatment. Sometimes called "pre-certification review."

A legal written agreement between a licensed healthcare facility, physician or other healthcare provider and a network or health plan.

Information that is sufficient to allow identification of an individual provider.

The extent to which services provided by the Network and by network providers are consistent with current standards of care and contribute to optimum health outcomes.

The extent to which services provided by the Network and by network providers meet the reasonable expectations of members for timely, efficient and courteous services.

A request by telephone for additional review of a utilization review determination not to certify, performed by the Peer Reviewer who reviewed the original decision, based on submission of additional information or a peer-to-peer discussion.

A recurrence is a return of symptoms of a previously treated condition that has been quiescent for 60 or more day and may require the reinstitution of therapy.

That phase of therapeutic care necessary for re-education or functional restoration of an injured body system or part. It includes treatment that relieves an exacerbation, but there must be continuing documented subjective and objective signs of improvement.

Review conducted after service(s) have been provided to the patient.

Review of information submitted to the Network for healthcare services that do not need clinical necessity certification nor result in a non-certification decision.

An educational offering designed to assist the provider in minimizing the potential of losses. Such a program may include the identification, analysis and evaluation of areas of potential loss as well as addressing specific incidents that may result in loss.

Penalties imposed by the Network on network providers who typically fail to abide by network administrative and clinical management requirements, criteria or standards. Such penalties may include fines, requiring the practitioner to participate in a specific program of remedial education or suspension or termination of the practitioner's network participation status.

A screening process that includes:

1. accepting structured clinical data (including diagnosis codes, procedures and procedure codes);
2. asking scripted clinical questions;
3. accepting responses to scripted clinical questions; and
4. taking specific action.

• applying clinical judgment or interpretation;
• accepting unstructured clinical information;
• deviating from the script;
• engaging in unscripted clinical dialogue;
• asking clinical follow-up questions, and,
• issuing non-certifications

Requirement of some health plans to obtain an opinion about the clinical necessity and appropriateness of specified proposed services by a practitioner other than the one originally making the recommendation.

Verification by the Network of a healthcare practitioner's qualifications and credentials based upon evidence obtained by legitimate means other than direct contact with the issuing source of the credential (i.e., copies of licenses and data base queries from established secondary sources).

A request to review a determination not to certify an admission, extension of stay or other healthcare services conducted by a Peer Reviewer who was not involved in any previous non-certification pertaining to the same episode of care.

Clinical information that is precise and permits exact matching against explicit clinical terms, diagnoses or procedure codes or other explicit choices, without the need for interpretation.

Treatment/care for patients having reached maximum therapeutic benefit, where periodic trials of therapeutic withdrawal fail to sustain previous therapeutic gains that would otherwise progressively deteriorate. Supportive care follows appropriate application of active and passive elements including lifestyle modifications. It is appropriate when rehabilitative and/or functional restorative and alternative care options, including home-based self-care and lifestyle modifications, have been considered and attempted. Supportive care may be inappropriate when the risk of supportive care outweighs its benefits, i.e., physician dependence, somatization, illness behavior, or secondary gain.

The treatment necessary to establish a stationary status of the patient at maximum therapeutic benefit.

For the purpose of defining the necessity of services administered under TRIAD contracts: Medical Necessity and Therapeutic Necessity shall be considered equivalent terms; and Therapeutic Care and Curative Care shall be considered equivalent terms; and Maximum Medical Improvement, or Maximum Therapeutic Benefit shall be considered equivalent terms. A healthcare condition exists in the presence of impairment (illness/injury) evidenced by recognized signs and symptoms, and likely to respond favorably to the treatment/care planned.

A written description of intended therapeutic actions divided according to relevant treatment/care goals and prognosis

Two or more diagnoses not related to one another for which treatment is rendered during the same office visit. (i.e., cervical spine strain/sprain and a medial epicondylitis; lumbar spine strain/sprain and tendonitis of the elbow).

Evaluation of the clinical necessity, appropriateness, and efficiency of the use of healthcare services, procedures and facilities under the auspices of the applicable health benefit plan; sometimes called "utilization review."

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