{"id":619,"date":"2020-11-30T19:30:06","date_gmt":"2020-11-30T19:30:06","guid":{"rendered":"http:\/\/localhost\/wordpress\/?page_id=619"},"modified":"2025-10-17T23:10:26","modified_gmt":"2025-10-17T23:10:26","slug":"utilization-management","status":"publish","type":"page","link":"https:\/\/dignityhealthmso.org\/index.php\/utilization-management\/","title":{"rendered":"Utilization Management"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; background_image=&#8221;http:\/\/localhost\/wordpress\/wp-content\/uploads\/2021\/01\/review-documents-form-male-female-e1611357567269.png&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_button _builder_version=&#8221;4.25.2&#8243; _module_preset=&#8221;default&#8221; button_url=&#8221;https:\/\/dignityhealthmso.access.mcg.com\/index&#8221; button_text=&#8221;MCG Guidelines: Transparency Portal&#8221; box_shadow_style=&#8221;preset6&#8243; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243;][\/et_pb_button][et_pb_text _builder_version=&#8221;4.25.2&#8243; _module_preset=&#8221;default&#8221; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243;]<\/p>\n<p><strong>MCG Guidelines<\/strong><\/p>\n<p>Please visit the MCG Transparency Portal above for a full list of the following guidelines:<\/p>\n<ul>\n<li>Ambulatory Care<\/li>\n<li>General Recovery Care<\/li>\n<li>Inpatient &amp; Surgical Care<\/li>\n<li>Recovery Facility Care<\/li>\n<\/ul>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; max_width=&#8221;100%&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.16&#8243; header_font=&#8221;|700|||||||&#8221; header_font_size=&#8221;3vw&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1>Utilization Management (UM)<\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=&#8221;4.16&#8243; max_width=&#8221;100%&#8221; custom_padding=&#8221;0px||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.16&#8243; text_font=&#8221;|600|||||||&#8221; text_font_size=&#8221;24px&#8221; text_line_height=&#8221;1.5em&#8221; custom_margin=&#8221;-28px|||||&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>Designed to benefit both providers and patients by putting patients on the right path to the right care in the right setting<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=&#8221;4.16&#8243; max_width=&#8221;100%&#8221; custom_padding=&#8221;0px||3px|||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;-29px||-37px|||&#8221; custom_padding=&#8221;||27px|||&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>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&#8217; medical, cultural, language, and geographic needs.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row column_structure=&#8221;1_2,1_2&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.16&#8243; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<p><span style=\"color: #ed7420;\"><strong>We aim to provide services that are:<\/strong><\/span><\/p>\n<ul>\n<li>Covered under the plan benefit<\/li>\n<li>Medically necessary<\/li>\n<li>Appropriate to the patient&#8217;s condition<\/li>\n<li>Rendered in the appropriate setting<\/li>\n<li>Professionally recognized standards of care<\/li>\n<\/ul>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><span style=\"color: #ed7420;\"><strong>We conduct reviews such as:<\/strong><\/span><\/p>\n<ul>\n<li>Prior authorization \u2013 to eliminate the need for unnecessary services helping reduce denials and ensuring patients are taking the proper path to care<\/li>\n<li>Concurrent review \u2013 Performed during the course of treatment<\/li>\n<li>Retrospective review \u2013 Assessing the appropriateness of completed care<\/li>\n<li>Benefit determinations using medical necessity criteria and transition of care programs<\/li>\n<\/ul>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>MCG Guidelines Please visit the MCG Transparency Portal above for a full list of the following guidelines: Ambulatory Care General Recovery Care Inpatient &amp; Surgical Care Recovery Facility Care Utilization Management (UM)Designed to benefit both providers and patients by putting patients on the right path to the right care in the right settingBacked by nationally [&hellip;]<\/p>\n","protected":false},"author":5,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-619","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/dignityhealthmso.org\/index.php\/wp-json\/wp\/v2\/pages\/619","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/dignityhealthmso.org\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dignityhealthmso.org\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dignityhealthmso.org\/index.php\/wp-json\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/dignityhealthmso.org\/index.php\/wp-json\/wp\/v2\/comments?post=619"}],"version-history":[{"count":9,"href":"https:\/\/dignityhealthmso.org\/index.php\/wp-json\/wp\/v2\/pages\/619\/revisions"}],"predecessor-version":[{"id":1572,"href":"https:\/\/dignityhealthmso.org\/index.php\/wp-json\/wp\/v2\/pages\/619\/revisions\/1572"}],"wp:attachment":[{"href":"https:\/\/dignityhealthmso.org\/index.php\/wp-json\/wp\/v2\/media?parent=619"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}