Utilization Management and Review (Dental)

Utilization Review (UR) activities are supported by objective, evidence–based, nationally recognized dental policies, guidelines and criteria. These policies, guidelines and criteria promote delivery of appropriate care to members in the most appropriate setting at the appropriate time. Dental Directors and Clinical Reviewers work closely with dental care providers to optimize dental 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 
• Letter Management Program
• Post–Service Review
• Dental Technology Assessment Reviews
• External Review Services
• Dental Consultation
• Dental 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.