The Physician Referral Criteria have been designed specifically for Health Utilization Managers who want to improve the consistency and relevance of their organization’s case determinations.

The PRC provide a concise, yet comprehensive set of peer reviewed, evidence-based criteria to help Medical Directors, Case Managers and other UM personnel proactively manage patient cases on a daily basis. In particular, the criteria are an indispensable resource for patient assessments and for pre-certification, concurrent and appeal reviews. Flexible and easy to use, the PRC offer real time support for both operational and content questions and are available on-line or on CD. 

Unlike other care guidelines, the PRC focus on the difficult, experimental and controversial procedures that frequently require review at the appeal level. Consequently, the PRC are updated continuously to reflect the dynamics of change in medical technology and user needs.

Criteria sets are developed through extensive review of evidence-based medical literature and supporting references are listed in the bibliography attached to each criteria set. Completed sets are then reviewed by appropriate panels of specialty-matched physicians to ensure consistency with current practice. Both Physicians and Utilization Managers contribute to the PRC by using, evaluating and requesting guidelines.

The PRC’s focus on emerging medical procedures, user participation and continuous updates make it the most flexible and current set of UM criteria available.