Example 02: Admission for Surgery

This is an example of a health services review request/response sequence between a specialist provider and a utilization management organization. The example shows how a specialist can request hospitalization for a patient from a UMO. The example also shows the UMO’s response.

Joe Smith is a subscriber to Maryland Capital Insurance Company. During a regular physical, Dr. James Gardener, Joe’s primary care physician, diagnosed a potential heart problem, acute myocardial infarction; unspecified site. Dr. Gardener had referred Joe to Dr. Susan Watson, a cardiologist for a consultation (see Business Scenario 1).

During the consultation examination, Dr. Watson determines that Joe’s diagnosis requires hospitalization and a surgical procedure, a triple bypass venous graft. The operation and recovery is to be at Montgomery Hospital.

Dr. Watson is required by Maryland Capital Insurance to submit a request for review seeking approval to perform the surgery at the hospital.

After review, Maryland Capital approves the request and responds.