What are the possible determinations when a review request is sent to a physician peer reviewer?
• Certification – The physician uses the available information and clinical judgment to render a certification determination. If further information is needed, peer to peer discussion is initiated between the physician reviewer and the treating physician. • Adverse Determination This is a general term for an unfavorable utilization or quality finding. Specific types of adverse determination include medically necessity non-certifications or denials, confirmed quality of care issues, and DRG change.
