Hinz Claim Management, Inc. Utilization Review Program is designed to monitor and determine medical necessity, appropriateness and efficacy of treatment plans and services utilized, while monitoring quality and continuing coordination of care.   The review is based on nationally recognized guidelines, ACOEM-medical practice guidelines, a system that identifies the utilization of health care services.

A Registered Professional Nurse performs the initial review, when indicated.  A Physician Consultant and/or same Specialty Physician, Licensed and Board Certified is available for review and consultation, when indicated and necessary.  Hinz Claim Management, Inc. performs prospective, concurrent and retrospective reviews.  In addition, when indicated, peer review, independent medical examination, second opinions and discharge planning will be initiated. 

 
Prospective Review is a review method of authorizing elective services to assure the necessity and reasonableness of the treatment being rendered.  Utilization review is conducted prior to the health care services or course of treatment including, but not limited to, outpatient procedures, office visits, durable medical equipment, and pharmaceuticals.  The review may also include services for which care has been initiated, prior to the request for prospective review that may include, but not be limited to an evaluation, same treatment provider and same condition/diagnosis and ICD-9 code.  Prospective review is assisted by the use of treatment protocols and practice guidelines.
 
Concurrent Review is a review of ongoing medical care, assessment of any additional requests for services beyond the original plan, but within the same episode of care.  This review involves the examination of the medical record during the time of care to assess the medical appropriateness and necessity of continued care.  Care including, but not limited to, inpatient, outpatient, office visits, durable medical equipment and pharmaceuticals.
 
Retrospective Review is an evaluation of care already performed.  This review is conducted after services have been performed which may include, but not limited to, inpatient, outpatient, office visits, durable medical equipment and pharmaceuticals.  Request for additional medical/clinical information maybe indicated.
 
Peer Review is indicated to determine if treatment, current and or recommended is within established guidelines or criteria.  A same Specialty Physician conducts this review when questions are identified with regard to appropriateness, necessity, frequency and/or duration of care.
 
Independent Medical Examination when indicated is scheduled to establish or determine diagnosis, treatment plan, prognosis or future medical needs and recovery timeframe.
 
Second Opinions when indicated are scheduled to confirm initial diagnosis and/or recommended plan of care.  
 
Discharge Planning supports the continuity of care when transitioning from current setting to home environment, based on individual specific needs.