Utilization Management

Your participation contract requires that you cooperate with our client's utilization management protocols provided they are consistent with industry standards. These programs vary. We recommend you call the phone number listed on the back of your patient's ID card to obtain additional information regarding a specific health plan's utilization management program.

The following are guidelines that we recommend to help you efficiently facilitate the utilization management process. Always:

  • Complete the pre-certification process;
  • Obtain authorization when required;
  • Provide clinical information within the requested time;
  • Exhaust entire appeals process; and
  • Keep your patient informed at each stage of the utilization management and appeals process.

Appealing Decisions

You and your patient have the right to appeal any utilization management decision according to the appeals process established by the participant's benefit program. Just as utilization management programs vary by health plan, so do appeals processes and guidelines. These variations also allow for compliance with any applicable state or federally mandated laws.

For detailed information on specific patient's appeals processes, call the telephone number on the back of your patient's ID card.