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Utilization management (UM)

The purpose of UM is to manage the use of health care resources to ensure that members get the most medically appropriate and cost-effective health care. The goal? Improving medical and behavioral health outcomes.

What does the UM team do?

What does the UM team do?

The UM team includes both clinical and nonclinical staff who monitor the use of certain services before delivery (prior authorization or PA). This review helps make sure services are:

 

  • Provided at an appropriate level of care and place of service
  • Included in the defined benefits and are appropriate, timely and cost effective
  • Accurately documented for accurate and timely reimbursement

Our UM team has expertise in medical and behavioral health care services. They get initial and ongoing training (at least annually) to combine clinical skills with service techniques that support our UM processes.

 

The UM team identifies both over- and under-utilization patterns for inpatient and outpatient services. Their reviews consider the characteristics and health care needs of member populations and the expected use of services. 

 

We don’t structure compensation for UM activities to provide incentives for denying, limiting or stopping medically necessary services to any member.

 

Learn about pharmacy PA

 

Learn about non-pharmacy PA (including concurrent reviews)

Contacting the UM team

 

You can leave a message with questions for us anytime. We return calls from 8 AM to 5 PM CT. Just call the number for the plan and service area you need.

We can also provide callers with TDD/TTY and language help.

 

When initiating or returning calls about UM questions, we require staff to identify themselves by:

 

  • Name
  • Title
  • Organization name

And upon request, they share specific UM requirements and procedures verbally with:

 

  • Facility personnel
  • Attending physicians
  • Other ordering practitioners and providers 

Also of interest: