The review staff includes registered nurses who perform initial screenings and board certified physicians with active licensure who review cases within their specialty area. They analyze the utilization of services to determine the clinical basis for service delivery and evaluate the timeliness and effectiveness of these services; when applicable, they recommend alternative care options and settings. In addition, the staff review the quality of care and identify opportunities for improvement.

These programs can produce significant benefits to patients, providers, and payers, including improvements in the appropriateness and medical necessity of care, the appropriateness of the setting in which beneficiaries receive care, and resource utilization.