Clinical review

Care is authorized by a clinician, not by the person who prepared the paperwork. The Clinical Reviewer is an active team member in the same organization who did not prepare the request. The reviewer reads the request, the verified evidence and the attachments, then records Approve, Reject or Return with a written reason. The decision names the revision it was made on and the exact verified evidence reference it relied on.

Approval authorizes the request and records the authorization date. Rejection declines it. Return sends it back to the coordinator with a reason, such as consent that does not cover the requested units. The reviewer also approves the close of each consultation session, checking the provider, timing, duration and encounter reference against verified evidence.

• Independent reviewer. The person who prepared the request cannot approve it. The reviewer is named on the decision.
• Decision tied to evidence. Each decision records the revision and the verified external evidence reference.
• A reason every time. Approve, Reject and Return all carry a written reason the coordinator can act on.

Agree who holds clinical review authority in each organization and the specialties they cover. Agree what the reviewer must see before deciding: the referral, the consent and any prior results. Agree when to return and when to reject. Set a turnaround target for requests in review, especially for urgent consults. Agree how a reviewer records that they hold no conflict with the provider.

A request for a cardiology follow-up reaches review at revision 3. The attached ECG report is listed as evidence, but its verification is still pending. The reviewer returns the request with the reason “ECG evidence not yet verified by the provider”. Two hours later the provider’s system verifies the ECG line. The coordinator re-routes the request, and the reviewer approves revision 3 with the ECG’s external record reference.

After the consultation, the cardiologist’s session is submitted for close. The reviewer checks that the provider, start date and 30-minute duration match the encounter evidence and approves the close. A coordinator who tried to approve the request herself would have been refused.

• Review Queue — Requests in review with patient and consent references, provider, units and revision.
• Sessions Awaiting Review — Submitted sessions with provider, start date and duration.
• Decision Register — Every decision with revision, outcome, reason, reviewer and date.

• Request to clinical authorization: The decision that authorizes care.
• Session to attested service: The decision that closes a session.

Check roles and permissions before naming reviewers.