Utilization Review Licensing in Pennsylvania

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Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Pennsylvania. For assistance with licensing, please contact us to learn about our software and managed license services.

Pennsylvania Utilization Review Entity Certification

Type of Review:

Medical Utilization Review

Agency:Pennsylvania Department of Health

Initial Registration

Agency:Pennsylvania Department of Health
Form:

Certified Review Entity (CRE) Application

Agency fee:

$1,000 for managed care plan utilization review, $2,000 for utilization review and external grievance appeal reviews.

Registration Renewal

Agency:Pennsylvania Department of Health
Form:

Certified Review Entity (CRE) Application (Renewal)

Agency fee:

$500 for managed care plan utilization review, $1,000 for utilization review and external grievance appeal reviews.

Due:

Triennially

Notes:

Renewals must be submitted at least 60 days prior to the expiration of the certification period.

Pennsylvania Resources

Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.

Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.

External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.

Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.

Prospective Review - Utilization review that occurs prior to treatment.

Retrospective Review - Utilization review that occurs after treatment and often after payment.

Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.

Utilization Review Agent (URA) - An entity that conducts utilization review.

Utilization Review Plan - A document of the procedures used during utilization review.

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