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Types of Review Services

Physician Review Services Across the Utilization Management Continuum

UM Physician Advisors LLC provides independent physician review services across the utilization-management continuum, including complex medical necessity, level-of-care, continued-stay, retrospective, appeals, post-acute, and related clinical determinations.

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Our approach

Structured review. Independent physician judgment.

We evaluate the complete clinical record, the patient's trajectory of care, applicable coverage requirements, and authorized clinical decision-support criteria when required.

Criteria guide the review process.Physicians make the clinical determination.
One clinical principle

The appropriate determination can change as the patient's condition changes.

A patient may appropriately begin in observation, later develop a complication requiring inpatient care, and subsequently become medically stable while awaiting post-acute placement. Each phase requires a separate clinical assessment.

Presentation→Severity→Treatment→Response→Complications→Continued Needs→Disposition
Core physician review services

Review types built around real utilization-management workflows.

Engagements can be configured for ongoing coverage, overflow capacity, targeted programs, second-level review, or complex-case escalation.

LOC
Hospital Level of Care

Outpatient / Observation vs. Inpatient Status Review

Physician review of the appropriate hospital patient status based on the clinical information available at the decision point, expected duration of medically necessary hospital care, severity of illness, treatment intensity, response to therapy, complications, and the evolving clinical trajectory.

Typical use: New admission, patient-status, outpatient/observation versus inpatient, or status-conversion question.

  • Outpatient/observation versus inpatient status
  • Observation-to-inpatient conversion
  • Whether inpatient status remains supported on subsequent days
  • Medicare Two-Midnight analysis when applicable
  • Procedure-status considerations when applicable
  • Retrospective patient-status review
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CS
Evolving Clinical Course

Concurrent & Continued-Stay Reviews

Evaluation of whether the patient's current condition continues to require the existing level of care as the hospitalization or treatment episode progresses.

Typical use: Day-specific review of whether acute or skilled needs continue.

  • Unresolved acute medical issues
  • Ongoing intensity of services
  • Clinical response and complications
  • Continued skilled treatment needs
  • Readiness for transition to a lower level of care
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RR
Completed Episodes of Care

Retrospective Medical Necessity Reviews

Physician analysis of completed hospitalizations or episodes using the documentation available for the dates under review while carefully separating prospective facts from later developments.

Typical use: Completed episode, disputed dates, or retrospective medical-necessity review.

  • Initial admission medical necessity
  • Appropriate level of care
  • Medically necessary hospital days
  • Continued-stay analysis
  • Changes in status during the episode
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P2P
Physician-to-Physician

Peer-to-Peer Reviews

Focused physician-to-physician discussion of complex or disputed medical-necessity and level-of-care questions.

Typical use: Physician-to-physician discussion of a disputed or complex determination.

  • Pre-discussion clinical record review
  • Identification of material clinical issues
  • Focused discussion of the disputed determination
  • Review of newly clarified clinical information
  • Documented outcome and rationale as required
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AP
Reconsideration

Appeals & Provider Disputes

Independent physician reconsideration of previously reviewed cases using the original record, the prior determination, and any newly submitted clinical information.

Typical use: Reconsideration using the prior determination, complete record, and new information.

  • Uphold or overturn analysis
  • Partial approval when clinically supported
  • New information review
  • Provider dispute and second-level review
  • Clear physician rationale for the final recommendation
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SNF
Skilled Nursing Facility

SNF & NOMNC Reviews

Assessment of continued skilled nursing facility medical necessity and readiness for transition to a lower level of care.

Typical use: Continued skilled need, functional progress, or transition/readiness question.

  • PT, OT, and ST progress
  • Functional status and assistance needs
  • Daily skilled nursing requirements
  • Rehabilitation potential and plateau assessment
  • NOMNC and safe-discharge considerations
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DD
Hospital Throughput

Delay in Discharge & Delay in Service Reviews

Clinical analysis that distinguishes ongoing acute medical necessity from hospital days prolonged by placement, disposition, or a pending service.

Typical use: Separate ongoing acute necessity from placement, disposition, or service delay.

  • SNF or rehabilitation placement delays
  • Facility acceptance or disposition barriers
  • Pending medically necessary procedures
  • Delayed services affecting safe discharge
  • Identification of the date acute-care necessity ended
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IRF
Post-Acute Care

Inpatient Rehabilitation & Post-Acute Reviews

Physician evaluation of whether the requested rehabilitation or post-acute setting is medically appropriate for the member's functional and medical needs.

Typical use: Rehabilitation intensity, functional need, and appropriate post-acute setting.

  • Functional deficits and rehabilitation potential
  • Therapy intensity and ability to participate
  • Need for multiple therapy disciplines
  • Medical complexity and physician oversight
  • Appropriateness of the requested setting
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PA
Requested Services

Prior Authorization & Medical Necessity Reviews

Physician review of selected procedures, tests, therapies, equipment, or other services when medical-director assessment is required by the contracting organization.

Typical use: Pre-service medical-necessity review of a requested procedure, therapy, test, or service.

  • Clinical indication and documentation
  • Applicable benefit and coverage requirements
  • Specialty or procedure-specific considerations
  • Alternative services when within scope
  • Clear approval or adverse-determination rationale
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What makes the review different

We review the clinical course—not simply the label attached to the case.

Diagnosis, procedure, length of stay, comorbidity burden, and placement needs can all be relevant. None should be interpreted in isolation.

Severity of illnessIntensity of servicesTreatment responseComplicationsFunctional statusCoverage frameworkDischarge readinessPhysician judgment
Possible review outcomes

The documented clinical facts drive the determination.

ApproveDenyModify Level of CareUpholdOverturnPartial ApprovalContinued StayNOMNCDelay in DischargeDelay in ServiceAdditional Clinical Review
How review is performed

A consistent physician-review pathway across review types.

1Clinical RecordReview documentation relevant to the requested dates and question.
2Clinical CourseReconstruct severity, treatment, response, complications and disposition.
3Review FrameworkApply relevant coverage requirements and authorized criteria when required.
4Clinical DeterminationIntegrate the complete record with independent physician judgment.
5Clear RationaleDocument the material facts and reasoning supporting the determination.
A SIMPLE OPERATING PRINCIPLE

From clinical question to physician determination.

01CLINICAL QUESTION

The clinical question starts the review.

02GOVERNING FRAMEWORK

Coverage requirements and clinical guidance frame the review.

03CLINICAL COURSE

The clinical course tells the patient’s story.

04PHYSICIAN JUDGMENT

Physician judgment completes the determination.

Coverage requirements and evidence frame the review. The patient’s documented clinical circumstances remain central to the determination.

Need physician review capacity?

Discuss ongoing coverage, overflow review, complex-case escalation, appeals, or a customized utilization-management program.

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Expanded Physician Clinical Review Services

Appeals & Provider Dispute Resolution (PDR)

Independent physician review of disputed medical-necessity, level-of-care, authorization, continued-stay, and related clinical determinations, with clear rationale addressing the complete record and applicable coverage framework.

Physician Review of Clinical Grievances

Clinical review of grievances requiring physician judgment, including appropriateness of care, medical necessity, access to clinically indicated services, or other substantive clinical concerns. Nonclinical grievance administration remains outside this service.

Clinical Validation Reviews

Physician-level assessment of whether a reported diagnosis or clinical condition is supported by documented clinical indicators, objective findings, diagnostic testing, treatment, and the overall record. Clinical validation is distinct from a coding-only audit.

Physician Reviewer Education & Calibration

Case-based education and calibration supporting consistent medical-necessity methodology, CMS coverage frameworks, documentation standards, clinical rationale development, and reviewer consistency. Proprietary criteria are used only when appropriately licensed or authorized; UMPA does not represent itself as an authorized MCG or InterQual training provider.