Utilization Review

Premier File Review has developed a nationwide network of credentialed, actively practicing, board-certified physicians, chiropractors, psychologists, physical & occupational therapists, and acupuncturists to perform independent and unbiased medical reviews (Prospective, Concurrent and Retrospective). Our panel of providers are actively practicing and are experienced in the utilization review process, having performed thousands of reviews.  Our providers render comprehensive, high-quality Medical necessity/Standard of care determinations to our clients that are timely and customizable which are supported by nationally recognized evidence-based treatment guidelines (i.e. – ODG) and/or state specific guidelines (i.e. – CA MTUS). 
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• The claims examiner/case manager/account manager refers the claim (file) to Premier and Premier’s UR coordinator reviews the claim to verify that the request(s) is (are) clear, the medical records are complete, and the appropriate provider and specialty has been assigned or we will assign the claim to the appropriate board-certified specialist.  Before assigning the claim, the UR coordinator also verifies whether any additional information is required to complete the review.

• The reviewing physician reviews the medical records and prepares a comprehensive summary of the medical records and makes a clinical recommendation based on the standard of care which conforms with state-appropriate, evidence-based treatment guidelines.  In the majority of cases, the reviewing physician performs at least 2 attempts to conduct a peer-to-peer discussion with the treating physician.  To increase contact rates, the staff of Premier will assist in coordinating the 2 physicians’ schedules.  The reviewing physician will discuss the patient’s case with the treating physician to better understand the treatment or diagnostic study being requested and attempt to come to a professional consensus.

• When the report is completed and uploaded into Premier’s system, our trained internal Quality Assurance staff, who are knowledgeable in all state regulations and requirements, reviews EVERY report to make certain the report contains all of the necessary information and a clear recommendation with the clinical rationale and the state-appropriate evidence-based treatment guideline citation, before it is submitted.  Our QA staff is also trained to make certain the format of the report is tailored to each of our client’s needs.  The Premier staff also works with the reviewing physician to facilitate a 100% accurate turnaround time (TAT) for our clients.  The typical TAT is 24 hours however same-day (rush) files can be completed when necessary.  

This process assures industry high peer-to-peer contact rates, extremely low appeal rates, and >99% accuracy rate.​

For sample reports, please contact Premier at Administrator@PremierFileReview.com.​

What Makes Premier File Review’s UR Process Unique:​