About Utilization Management
Utilization management (UM) is a process that helps members get the right care in the right place. This process helps us decide if certain outpatient care, inpatient hospital care or procedures are medically necessary. UM also helps us decide if the services will be covered by our members’ health plans.
Decisions are based on what is right for each member based on the type of care and service. We look at standards of care that are taken from:
- Medical policies
- Nationally recognized clinical guidelines
- Your health benefits
Associates, consultants or other providers are not rewarded or offered money or incentives for denying care or a service, or for supporting decisions that result in using fewer services. Your health plan doesn’t make decisions about hiring, promoting or firing these individuals based on the idea they will deny benefits. Decisions in UM are based only on appropriateness of care and service and existence of coverage.
To learn more about our UM process, call us toll free, Monday – Friday, from 8:30 a.m. to 5:00 p.m., at the Member Services number on the back of your ID card (more hours may be available in your area).
If you call after normal business hours, you can leave a private message. Our staff will return your call on the next business day. Calls received after midnight will be returned the same business day. See our language assistance article to learn how to get help in your preferred language.