The Utilization Management (UM) Program goal is to provide continuity of care, coordination of services and improved health outcomes, while increasing the effectiveness and efficiency of services provided to Members.
Licensed nurses may authorize services under the direction of the medical director, but they do not make medical necessity denial decisions. They apply UM criteria to make decisions and utilize their clinical knowledge while considering the individual needs of the Members. The Plan’s medical director is available to the nurses for consultation and to make medical necessity denials.
Health Services is committed to ensuring medically necessary quality care in appropriate settings. UM nurses and Providers—working closely with hospital staff and attending Providers—perform pre-service review, concurrent review and post-service review, utilizing nationally recognized, evidence-based criteria adopted by our network of Providers, ensuring that services being performed and medical equipment being ordered are appropriate.
Utilization Management Guidelines
- Botox Supplemental Clinical Guideline
- Chiropractic Services Guideline
- Custodial Care Guideline
- Genetic Testing Guideline
- Home Enteral Nutrition Guideline
- Intravenous Sedation and General Anesthesia for Dental Services Guideline
- Nusinersen / Spinraza Guideline
- Nursing Facility Guideline
- Physical, Occupational, and Speech Therapies for Children under the Age of 21 Years Guideline
- Transgender Services Guideline