Utilization Management and Review

Utilization Review (UR) activities are supported by objective, evidence–based, nationally recognized medical policies, clinical guidelines and criteria. These policies, guidelines and criteria promote delivery of appropriate care to members in the most appropriate setting at the appropriate time. Medical Directors, nursing and pharmacy staff work closely with health care providers to optimize health care outcomes.

The Utilization Management (UM) Program provides a structure to monitor and facilitate the delivery of high quality, individualized care to program participants.  The Program includes end-to-end processes such as:

  • Intake/Notification
  • Prior Authorization/Prospective/Pre-Service Review/Clinical Coverage Review
  • Inpatient Care Management/Concurrent Review/Discharge Planning
  • Letter Management Program
  • Post–Service Review
  • Pharmacy Management
  • Medical Technology Assessment Reviews
  • External Review Services
  • Physician Consultation
  • Medical Claims Review
  • Clinical Appeals

The Program also describes other Quality Programs that ensure member access to quality, affordable care.

For a full description of the UM Program, please see the the Utilization Management Program Description.