Behavioral Reviews

FOCUS has extensive expertise in conducting Behavioral Health medical necessity reviews.  We have a broad panel of Board Certified Psychiatrists with licensure throughout all 50 States and the District of Columbia.  Our panel offers sub-specialties in Child/Adolescent Psychiatry, Geriatric Psychiatry and Addiction Medicine.  We also have reviewers who have extensive experience managing and reviewing Eating Disorder services and Applied Behavior Analysis.

 

We provide services for both Commercial Insurance and Government Services and can provide reviews for the entire continuum of care from Inpatient treatment through Outpatient treatment, including Community Based Services, ABA Therapy, Transcranial Magnetic Stimulation, Electoconvulsive Therapy, and Psychological/Neuropsychological testing.

 

We provide support for all levels of internal review available through the Health Plan, including Pre-service, Concurrent/Continued Stay, Post-Service, Initial Determinations, Reconsiderations and Appeals.

 

In addition to Medical Necessity reviews, FOCUS also provide Case Shaping/Consultation for complex or
co-morbid cases.

 

All of our reviews include evaluation and discussion of any potential Quality of Care concerns that are identified by the Health Plan staff or as part of our clinical review.

Pharma Reviews

In addition to traditional Utilization Management, our panel of Behavioral Health reviewers is also able to support our Health Plan partners with managing Behavioral Health Pharmacy utilization.  We support prior authorization processes with Initial Determinations, Reconsiderations and Appeals.  We also provide Case Shaping/Consultation for complex or co-morbid cases.

Medical Reviews

FOCUS also provides reviews services for Medical Utilization Management.  We primarily support Musculoskeletal and Pain Management specialties at this time, but have the ability to expand our panel of specialists to accommodate the needs of our clients.  Our reviewers are all Board Certified in their respective specialties and have extensive experience treating patients with musculoskeletal and pain management issues. 

 

We provide support for all levels of internal review available through the Health Plan, including Pre-service, Concurrent/Continued Stay, Post-Service, Initial Determinations, Reconsiderations and Appeals.

 

In addition to Medical Necessity reviews, FOCUS also provide Case Shaping/Consultation for complex or co-morbid cases.