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Medical Review Criteria for Managing Care®: Ambulatory
- The bible for health plan benefit interpretation guidelines.
- More than 2,000 detailed clinical review criteria guidelines and evidence-based benefit interpretations.
- Provides utilization management and claims departments with essential information to assist in medically-necessary benefit determinations.
- Includes specific indications for medically necessary ambulatory care or inpatient tests and procedures.
- Extensive literature references and other authoritative resources in each guideline, with web links.
- List of LOS benchmarks by DRG for Medicare, commercial and Medicaid populations.
Acute Care Inpatient Guidelines
- More than 350 guidelines that contain acute care inpatient review criteria with MS-DRG and APR-DRG Length of Stay data.
- Evidence-based, with comprehensive reference links.
- Includes a section entirely devoted to Managing Unplanned Readmissions, which includes issues, innovative programs, resources and strategies needed to manage CMS targeted readmission diagnoses and avoid financial penalties.
- Detailed review criteria by MS-DRG focus on medical necessity and appropriateness of care.
- Search guidelines by DRG, CPT/HCPCS, ICD-9 or keyword.
Managing Physical/Occupational/Speech Therapy and Rehabilitation Care
- Detailed review criteria for adult/pediatric OT, PT, speech therapy plus therapy-related DME.
- Detailed review criteria guidelines for inpatient rehabilitation unit/hospital admission, continued stay and discharge.
- The recommended number of visits required to treat specific conditions and instruct patients for self-directed home care.
- Resources include example protocols and quality monitors throughout including the Oregon Pediatric guidelines for rehabilitation, web sites.
Managing Behavioral Healthcare; Review Criteria, Case Management
- Detailed behavioral health review criteria guidelines and benefit interpretations for inpatient and outpatient care by diagnostic entity, including office visit edits.
- Strategies for quality-based efficient delivery of integrated effective behavioral healthcare management.
- Adult and children’s behavioral health LOS and CM.
Managing Post-Acute Care and Other Extended Care Services
- Comprehensive policies, procedures and plans for quality-based, cost effective management strategies and review criteria for post-acute care in a subacute unit, SNF, institution, hospice and/or the home under managed care contracts and Medicare.
- Review criteria guidelines/benefit "interps".
- Numerous forms and coverage information.
- Extensive references.
- Resources such as stroke, cardiac and pulmonary rehabilitation guidelines.
Disease State Management Strategies I: Clinical Guidelines for Primary Care
- Medical (asthma, COPD, diabetes, hypertension, smoking cessation, cardiovascular disease prevention, hormonal therapy) and obstetrical (LOS and the prevention of preterm deliveries) clinical guidelines plus “Wellness” or preventive healthcare standards by age and sex and Prevention of Stroke & CAD. Resources include related patient education, extensive references and web links.
Disease State Management Strategies II: Clinical Behavioral Health Guidelines
- This popular behavioral health resource features detailed clinical guidelines for the effective management of common, costly disorders such as ADHD, Alzheimer’s disease, alcohol abuse or dependence, major depression, bipolar, obsessive-compulsive, anxiety/phobias/panic disorders including PTSD, personality, conduct and oppositional defiant disorders. References and resource materials plus websites follow each guideline. The American Psychiatric Association DSM 5 diagnostic criteria is applied.
Case or Care Management
- Plans, policies, procedures and strategies that work to improve quality and efficiency of care while controlling costs for medical and mental health care.
- This application is ideal for accreditation and quality improvement strategies.