UM105 – Peer Review Process

This document outlines the peer review process utilized by Colorado Access for providers requesting service reviews. It includes definitions of key terms, procedures for requesting peer reviews, and specific timeframes for both prospective and concurrent reviews. The policy aims to ensure that services are medically necessary and appropriately authorized. The procedures detail the methods for communication between healthcare facilities and the Colorado Access medical directors regarding adverse benefit determinations. Overall, it emphasizes the importance of timely reviews to reflect the current clinical status of members.