AI Utilization Review (UR) in Alleva InCheck 

Utilization Review (UR) is a new feature in Alleva InCheck that helps streamline the process of completing UR forms for clients. Like AI Chart Audits, this feature uses AI to scan a client's chart and pre-fill the UR form based on their treatment information. Reviewers then verify the AI's answers before submitting the form.

At a high level, a UR is a customizable form that gets completed and used to support a request for continued or updated authorization from an insurance company. This feature automates the creation of those forms and uses AI to help fill them out.

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Accessing Utilization Review

1. In InCheck, go to the Utilization Review tab.
2. From here, you can create a new UR manually or view existing reviews under the Reviews tab.

Creating a UR Manually

1. Click New Review and start typing the client's name. Select the client from the dropdown.
2. Once you select a client, the form will automatically pre-fill:
   • Level of care
   • MRN
   • Authorization number (pulled from their last authorization in the EMR)
   • Authorization due date
   • Payer (insurance company)
3. Select the review type (for example, continued stay or initial review).
4. Set the priority.
5. Click Create.

A success message will appear, and the new review will show up under the Reviews tab.

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Using AI Prefill

1. Open the review you just created by clicking View.
2. This opens the actual UR form. UR forms are editable and managed under Settings > Custom Forms, so different forms can be set up for different levels of care and payers.
3. Click the AI Prefill button. This scans the client's chart and answers the form's questions automatically, the same way AI Chart Audit works.
4. Once AI Prefill finishes, you'll see:
   • A summary of all the AI's answers
   • Any warnings about the UR
   • An overall score for the form
   • The full AI analysis for each question
5. Click into the AI analysis to review how each answer was generated.
6. Go through each answer and verify it's accurate, editing as needed.
7. Add any additional notes at the bottom of the form if needed.

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Completing and Downloading a UR

1. Select a recommendation at the top of the form:
   • Continue current level of care
   • Step up level of care
   • Step down level of care
   • Discharge
   • Additional review needed
2. Click Submit Form. No sign-off is required.
3. Click the Print Review at the top of the finished form, download, and send to the insurance company.

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Auto-Pull for Upcoming URs

InCheck can automatically create UR forms ahead of time based on authorization due dates:

• The auto-pull window is configurable (currently set to 7 days).
• On each pull, the system checks all client authorizations expiring within that window and automatically creates UR forms for them under Reviews.
• AI Prefill does not run automatically on these auto-created forms. This is intentional, since AI Prefill should be run as close to submission as possible so it reflects the most current chart information.
• Reviewers will go through the list, run AI Prefill when they're ready to complete each one, verify the answers, and submit.
  
  

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Assigning and Reassigning Reviewers

• URs can be assigned to a specific InCheck user as the reviewer.
• To reassign a review, select the review, use the Reassign To dropdown, select a different user, and click Reassign.
  
  

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Overview Tab and Reports

The Overview tab provides reporting on UR activity, including:

• Total reviews, pending reviews, completed reviews, and overdue reviews (based on due date)
• Trends over time showing how many URs have been completed
• Reviews by type and priority, both pending and completed
• Reviewer workload, showing all users with URs assigned to them and how many each has open
• Overdue reviews, showing all reviews past their due date regardless of assignee
• Upcoming reviews, showing reviews assigned specifically to the logged-in user

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Key Takeaways:

• A UR is a customizable form used to request continued or updated authorization from an insurance company.
• AI Prefill scans the client's chart and fills out the form, but all answers should be verified before submitting.
• Auto-pull creates UR forms ahead of due dates, but AI Prefill must be run manually at the time of completion.
• Reviews can be assigned, reassigned, and tracked through the Overview tab's reporting.