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Utilization Management

The goal of our Utilization Management (UM) program is to encourage the highest quality of care, in the most appropriate setting, from the most appropriate provider. Our philosophy is that medically appropriate care is cost effective. Through the Utilization Management program we seek to avoid over-use and under-use of medical services by making clinical coverage decisions based on available evidence-based guidelines.

Pre-service reviews are performed for medical services and medications that require pre-authorization. Concurrent reviews are performed when members are hospitalized to ensure that care is provided in accordance with evidence-based guidelines and to promote the transition of care from the hospital to home or another health care setting.  Post-service reviews occur after medical care has been received. UM reviewers are not compensated or rewarded for denials of coverage. 

Clinical coverage decisions regarding medical services are only made by board-certified physicians. Clinical coverage decisions regarding medications that require pre-authorization are made by registered pharmacists or board-certified physicians. 

Some services that providers may recommend are not necessarily covered as part of a member’s health benefit plan. If you have questions about what services are covered, refer to your plan document or call the toll-free Customer Service number on the back of your member ID card.




 
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Search our online directory to Find a Physician or Facility. For a paper provider directory or assistance finding a provider, please call the Customer Care number on the back of your health plan ID card.


 
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