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Utilization review: a practical approach for physicians.

D C Williams¹, L M da Costa

¹Rhode Island Department of Health, Providence 02908, USA. donw@doh.state.ri.us

Medicine and Health, Rhode Island

|June 30, 2000

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Rhode Island's utilization review (UR) process includes an appeals system that is frequently successful. Patients and providers can seek guidance on UR regulations and patient rights from the Office of Managed Care Regulation.

Area of Science:

Health Law
Healthcare Policy
Regulatory Compliance

Background:

Rhode Island has established specific rules and regulations governing Utilization Review (UR) within its healthcare system.
A formal appeals process exists for decisions made during the UR process.

Purpose of the Study:

To inform stakeholders about the existing UR framework in Rhode Island.
To highlight the effectiveness of the UR appeals process.
To provide contact information for inquiries regarding UR, appeals, and patient rights.

Main Methods:

Analysis of Rhode Island's Utilization Review Act and associated regulations.
Review of data on the success rates of the UR appeals process (as indicated by Table 1).
Provision of contact details for the Office of Managed Care Regulation (OMCR) for further information.

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Main Results:

The appeals process within Rhode Island's UR system demonstrates a high rate of success.
The Office of Managed Care Regulation (OMCR) serves as a resource for understanding UR, appeals, and related rights.

Conclusions:

Rhode Island's UR appeals process is an effective mechanism for addressing disputes.
Stakeholders are encouraged to utilize the provided resources for clarification on UR regulations and patient advocacy.