MCC has adopted a streamline approach to UR that is systematically designed to alert to the possibility of excess claims.
Pre-certification process—determines medical necessity
Concurrent Review—continuing collection of clinical data to support continued services
Retrospective Review—determines medical necessity after services have been rendered
MCC utilizes the nationally recognized Milliman Guidelines as its clinical guidelines when performing reviews.
Our Medical Director provides oversight of all clinical programs including utilization management. He performs medical reviews and pre-determinations as needed on a daily basis. As the medical director, he is the sole person at MCC that can deny services for medical necessity. He works with the Vice President of Clinical and Client Services on medical necessity criteria, appeals, and continuing education. He also oversees and interacts with MCC’s Peer Review Committee members as necessary.
MCC’s Peer Review board is a panel of board certified physicians who are retained to provide insight and expertise in their area of medical specialty. They work with the medical director as needed or requested, providing both verbal and written consultation as needed or requested by the MCC Medical Director and/or third party administrator or stop loss carriers/underwriters.