Utilization Management (UM)

Designed to benefit both providers and patients by putting patients on the right path to the right care in the right setting

Backed by nationally recognized evidence-based guidelines, UM is committed to ensuring services are properly utilized by patients. We help you ensure that patients receive high-quality, medically necessary care that is supported by a robust provider network which grows and changes to meet patients’ medical, cultural, language, and geographic needs.

We aim to provide services that are:

  • Covered under the plan benefit
  • Medically necessary
  • Appropriate to the patient’s condition
  • Rendered in the appropriate setting
  • Professionally recognized standards of care

We conduct reviews such as:

  • Prior authorization – to eliminate the need for unnecessary services helping reduce denials and ensuring patients are taking the proper path to care
  • Concurrent review – Performed during the course of treatment
  • Retrospective review – Assessing the appropriateness of completed care
  • Benefit determinations using medical necessity criteria and transition of care programs