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Utilization Management

The goal of Gold Coast Health Plan's (GCHP) Utilization Management (UM) Program 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 use 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.

GCHP's Health Services Department 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, concurrent and post-service reviews using nationally recognized, evidence-based criteria adopted by the Plan's network of providers, ensuring that the services being performed and the medical equipment being ordered are appropriate.

Utilization Management Guidelines

Administrative

Medicine

Rehabilitation Therapy