Which party is authorized to modify, delay and deny treatment in UR when it involves a specific specialty?

Which party is authorized to modify, delay and deny treatment in UR when it involves a specific specialty?

• A. Licensed medical provider in that specialty
• B. Certified physician
• C. Licensed physician's assistant
• D. Claims adjuster

Answer: (A)

In utilization review for care that involves a specific specialty, the authority to modify, delay, or deny treatment rests with a licensed medical provider who actually practices in that specialty. This ensures the decision is guided by hands-on, specialty-specific medical knowledge and current standards of care, rather than by non-clinical staff or generalists. A licensed physician assistant typically cannot make final UR determinations about specialty care, since their authority is supervisory and limited by scope of practice. A claims adjuster handles policy and payment issues, not clinical medical necessity decisions. A physician who is board-certified might not have licensure in the exact specialty required for the case, which is why the essential criterion is licensure in that specialty. Therefore, the correct person is the licensed medical provider in that specialty.

In utilization review for care that involves a specific specialty, the authority to modify, delay, or deny treatment rests with a licensed medical provider who actually practices in that specialty. This ensures the decision is guided by hands-on, specialty-specific medical knowledge and current standards of care, rather than by non-clinical staff or generalists. A licensed physician assistant typically cannot make final UR determinations about specialty care, since their authority is supervisory and limited by scope of practice. A claims adjuster handles policy and payment issues, not clinical medical necessity decisions. A physician who is board-certified might not have licensure in the exact specialty required for the case, which is why the essential criterion is licensure in that specialty. Therefore, the correct person is the licensed medical provider in that specialty.