Utilization Management

Important Information for Members

Utilization management (UM) makes sure you get the right health care when you need it. There are several types of UM:

  • Utilization review before care. This evaluates a planned hospital stay or appointment before it begins. Examples are prior approval of some treatments at the doctor’s office and day surgery.
  • Utilization review during care. This is used to watch patient care while it happens. It helps determine when care may no longer be medically necessary. An example is ongoing review of a hospital admission during your stay. Part of utilization review during care involves active case management and planning for when you leave the hospital.
  • Case management services. We may provide case management services to some members who have serious or complicated health conditions. These members may have conditions like high risk pregnancies, cancer or AIDS. Case management keeps track of how well treatment is going. We may contact you and your doctor to discuss certain things. These may include care plans, goals and the right use of resources.
  • Planning for when you leave the hospital. We coordinate and manage your care after you leave the hospital or other health care facility. The planning happens while you are still in the hospital.
  • Post treatment utilization review. Evaluates health care services after they are provided.
  • If utilization review results in your service(s) being denied, you have the right to file an internal appeal with the Plan. An appeal is an opportunity for you or your provider to send additional information and the Plan will take another look at your request. You may file an appeal either verbally or in writing. For additional information, please check your Member Handbook.

Please see the Member Handbook and Covered Services List for additional information, including covered and non-covered benefits; any restrictions to services, benefits or the provider network; and a summary of pharmaceutical management procedures.  Click the ‘Find a Provider’ link at the top right of the page to find out about our providers. Please see Your Privacy for our privacy policies. Please see a summary of our utilization management procedures.