|What is Care Management?||Care Manager Nurses help people with their health care and community service needs, at the right time, right setting and for the best value. We are conscientious to the cultural and linguistic preferences of our members and their supports. Our Care Management program offers our members individual attention to help meet their health care goals. Services include education, advocacy, and coordination of your needed services. This program is no-cost for our members who want care management nursing services.|
|What is Utilization Management?||Our Utilization Management Team assists members to get the right care at the right time to allow for the best outcome based on nationally recognized evidence-based guidelines. Your doctor is required to get prior authorization for some services. You or your doctor can request an expedited response if a delay could be hazardous for you. In some situations, a service may be reviewed for medical necessity and coverage after the service is rendered. Members have the right to request an appeal or reconsideration of all Utilization Management decisions.
Services that require a referral or authorization can be reviewed below.
|Utilization Review Guidelines||
Care Coordination will be provided through our Care Management Department for the following:
We encourage you to submit a pre-service request for medical review of the listed services.
The listed services require medical review for payment determination.
We require notification for any inpatient admission. U of U Health Plans will be monitoring all inpatient hospital stays, including skilled nursing facilities and rehabilitation services. Services deemed ‘medically necessary’ do not guarantee payment if coverage terminates, benefits change, benefit limits are exhausted or pre-existing conditions apply.
Utilization review means a review and confirmation program that determines medical necessity of any care service or treatment. In general, all covered benefits are based on medical necessity and utilization review is not limited to the above list.