Rising’s nurses and physicians guide payers and patients through the medical care process. Our Utilization Review (UR) services deliver appropriate, clinically sound treatment recommendations that result in more rapid recoveries and cost effective outcomes.

Clinical Expertise, Evidence-Based Decisions

Here’s a snapshot of Rising’s Utilization Review program:

  • URAC Accredited
  • Prospective, Concurrent, and Retrospective reviews
  • Pharmacy / Drug Utilization reviews
  • National capabilities with licensures in appropriate jurisdictions
  • Evidenced-based national guidelines or state specific guidelines (e.g. ODG for Texas and MTUS for California) are applied to both approvals and modifications / denials
  • National panel of credentialed, board-certified physicians
  • Peer reviews conducted by physicians of the same specialty
  • Single digit appeal rates in every state – significantly lower than industry averages
  • UR-Bill Review system integration, with adjuster treatment alerts

Program Results Backed by Transparency

We help you understand the value you’re getting, including:

  • Cost savings reports on denied / modified services – hard savings only
  • Compliance metrics by state measuring Utilization Review turn-around time

State-Specific Appeals Process

Utilization Review Services: