How does utilization management work?
To ensure you receive quality health care in the most appropriate setting, physicians, nurses, and other staff in our Medical Management Department work with your primary care physician and other health care professionals to coordinate:
- Pre-authorization - Certain services and prescription drugs require our prior authorization to ensure coverage. This means the physician ordering the treatment or service must contact us to request prior approval. Authorization for certain services requires them to be medically necessary and provided by participating providers.
- Concurrent review and case management - Our medical directors and nurses actively follow members who are hospitalized to ensure appropriate levels of care and service. These professionals coordinate with your physician for continued care in alternate settings if appropriate -- transfers to other institutions, coordinating discharge from the hospital, continued skilled care, home health care, therapies, etc.
- Retrospective review - Medical Management professionals also review certain services after they are delivered to determine if they were medically necessary and appropriate.