Utilization review is conducted for delegated and non-delegated hospitals through retrospective medical record review and concurrent medical record review respectively.  This review is performed through a statistically valid random sample of hospital discharges for which services are evaluated for medical necessity and correct billing.

DRG reviews are also performed on a statistically valid random sample to determine whether the coding of diagnoses and procedures, and other medical record information reflects accurate payment to the hospital.  We evaluate readmissions to the same hospital within seven (7) days to determine whether the two stays should be combined under state regulations, and to determine whether there were any quality issues causing the readmission.

Quality of care reviews are performed on every record selected in the random sample to determine if standards of care were met and whether there were any hospital-acquired conditions.

For any adverse finding, hospitals are given the opportunity for a reconsideration review and the case is reviewed by a New Jersey licensed physician qualified in the clinical field in question.