Click below to identify the criteria used in determining when Utilization Review or Telephonic Case Management are called for.

 

UR/TCM REFERRAL CRITERIA

insurance claims management by TRISTARClick below to identify the criteria used in determining when Filed Case Management are called for.

 

FCM REFERRAL CRITERIA

insurance claims management by TRISTARClick below to view the advantages of Case Management.

 

CASE MANAGEMENT ADVANTAGES

insurance claims management by TRISTAR

REQUEST FOR SERVICE

 

The first step in securing our Managed Care Services is to submit a Request for Services referral form. Download the form below.

 

DOWNLOAD FORM

FOR CURRENT CLIENTS

 

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TRISTAR CA MPN

 

Entire PPO Directory

To Report Fraud:
Contact our hotline at
(323) 253-0376
or
tristarhotline@sbcglobal.net

EMAIL TRISTAR MANAGED CARE

UR/TCM REFERRAL CRITERIA

insurance claims management by TRISTAR

Utilization Review Referral Criteria

  • Surgery
  • Chiropractic treatment – over 6 visits
  • Physical therapy -- over 6 visits
  • Occupational therapy – over 6 visits
  • Diagnostic testing (MRI, CT scan, EMG/NCV, bone scan)
  • Acupuncture
  • Discogram/arthrogram/myelogram
  • Epidural steroid injections
  • Facet and trigger point injections
  • Bone and muscle stimulators
  • Home health care/ transfer of care to skilled nursing/convalescent/ residential facility
  • Pain management - Referral to pain management physician and/or interdisciplinary rehabilitation program
  • DME over $200 per item for rental or purchase (includes TENS, IF, Cold Therapy, CPM).
  • Work hardening/ work conditioning programs
  • Gym membership or special exercise programs (Pilates, Tai Chi)
  • Chemical dependency
  • Weight loss program
  • Massage therapy
  • Botox injections
  • Gastric bypass
  • Cold laser therapy
  • Computerized spinal decompression
  • Any unusual claim which the adjuster feels may warrant intervention

Telephonic Case Management Referral Criteria

  • Inpatient hospitalizations
  • Cumulative trauma with anticipated loss time
  • Accepted psychological claims/stress claims
  • All cases with over 14 days anticipated TTD
  • Inconsistent medical findings- subjective complaints can not be supported by objective findings
  • Multiple treating physicians
  • Frequent change of primary treating physician
  • Pre-existing conditions that may prolong treatment (i.e., diabetes, hypertension, heart problems)
  • Patient with history of drug/alcohol abuse
  • Continued treatment by non-specialist beyond 30 days
  • Non-compliant treating physicians
  • RTW issues- continued/prolonged modified duty, unchanged work restrictions
  • Continued treatment with no MMI in sight
  • Roving diagnosis-continually changing diagnosis (i.e. starts as carpal tunnel, changes to epicondylitis, changes to rotator cuff cervical strain)