Utilization Management

Our utilization management program focuses on maintaining quality care for inpatient and outpatient services in a cost-effective manner. We continually evaluate the medical necessity, appropriateness, and efficiency of the use of health care services, procedures and facilities.

Pre-authorization of Services

The Health Plan provides oversight of health care services to members, ensuring services are medically appropriate and access to care is performed in a timely, effective, and efficient manner. Certified registered nurses help members get the care they need, when they need it using nationally recognized criteria. Medical directors will review any service that do not meet the criteria.

Hospital Review

When our members enter the hospital for a an elective procedure or as an emergency, registered nurses from The Health Plan receive clinical information from the hospital about the member's care and progress. The nurses monitor the quality of care that a member receives during their stay in the hospital and will assist with discharge planning.