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Determination - UC 13: Medical review of determination

Updated on January 31, 2022
Pega Foundation for Healthcare
  1. Retrieve the case from MDReview@MyHealthPlan workbasket.

  2. System displays request details.

  3. Edit Guideline/Policy reference used for reconsideration. The following Guideline/Policy reference information can be edited:
    • Policy Number
    • Medical Policy Date
    • Medical Policy name
    • Guideline number
    • Guideline name
    • Page number
  4. Select disposition.

  5. Edit comments and click Submit to record MD Review’s disposition.

    Refer UC8 for determination resolution communication.

  • Previous topic Determination - UC 12: Review and research determination case
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