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Types of Review Services

Physician review across the utilization-management continuum.

UM Physician Advisors LLC provides independent physician review for complex medical-necessity, level-of-care, continued-stay, retrospective, appeal, post-acute, and related utilization-management decisions.

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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

Inpatient & Observation Reviews

Physician assessment of the appropriate hospital level of care based on the patient's presentation, severity of illness, treatment requirements, response to therapy, complications, and anticipated clinical course.

  • Inpatient versus observation
  • Observation versus outpatient care
  • Observation-to-inpatient conversion
  • Procedure-specific level-of-care considerations
  • Medicare patient-status considerations when applicable
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.

  • 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
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.

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

Peer-to-Peer Reviews

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

  • 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
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.

  • 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
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.

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

  • 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
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.

  • 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
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.

  • 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
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

The diagnosis starts the review.

The clinical course tells the story.

Physician judgment completes 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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