Utilization Management Program and Medical Policy and Review

Our Utilization Management and Medical Policy and Review programs:

  • Ensure employees receive appropriate and cost-effective medical care
  • Develop tools and programs that promote effective care
  • Implement medical guidelines to make clinical decisions
  • Offer actionable information to help with employee care

Utilization Management

Our Utilization Management program controls healthcare costs by reviewing inpatient and select outpatient services and comparing them against medical necessity guidelines. A medical necessity is a service, supply and/or prescription drug that is required to diagnose or treat a medical condition. The review process ensures your employees have access to appropriate care for their specific medical condition.

Before your employees are discharged from the hospital, our Utilization Management nurses work with the hospital to ensure they have a comprehensive discharge plan and the needed support to improve their health. Our professional clinical team works closely with physicians and uses evidence-based guidelines to help improve safety, reinforce the importance of sticking to established plans, improve self-care and contain costs by avoiding relapses and readmissions.

Medical Policy and Review

Our Medical Policy and Review program helps to control healthcare costs by making sure your employees receive safe and medically proven care. We use medical policies, which take into account new approved healthcare technologies that benefit members, to determine what’s covered under your benefit plan. Guided by these policies, providers are reimbursed only for services consistent with current scientific data, medical knowledge and clinical practice standards. These policies also ensure that members receive the right care.

Our goal is to provide you with top quality programs and services. The Utilization Management and Medical Policy and Review program will enable you and your employees to decrease healthcare costs while receiving suitable and personalized care.