Wiki Looking for a Utilization Management Rule

[aaperry]

I am currently working on a project searching for the source of a utilization management rule. I am looking for the rule that 2 obstetrical ultrasounds will be paid without a prior authorization, but 3+ need prior authorization. Any help as to where to find the source of this rule is greatly appreciated. I've searched the CMS website to no avail. Thanks in advance.

 

[conniekryzer]

I am currently working on a project searching for the source of a utilization management rule. I am looking for the rule that 2 obstetrical ultrasounds will be paid without a prior authorization, but 3+ need prior authorization. Any help as to where to find the source of this rule is greatly appreciated. I've searched the CMS website to no avail. Thanks in advance.

Hi - I believe this would be a payer specific rule but what payer I do not know. I have not heard this rule before. But it does sound like it would be a certain payer and their specific rule but you would need to know what payer. You could search some of the major payer websites and look for their UM process or prior authorization process for this test. That is labor intense but I am not sure how else you would find that out unless someone knows and can respond. Sorry to not be of much help.

 

[csperoni]

Yes, this would definitely be a payer specific rule. Typically each carrier's website has a section for this type of information.