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    CARE MANAGEMENT & UTILIZATION MANAGEMENT

    If you have a serious or chronic condition and would like care management services, please call 1-888-271-5870, option 2. Our staff members are available for members and providers. The hours of operation are Monday through Friday 8 am to 6 pm (excluding holidays). TDD/TTY services are available. You may contact Utah Relay Services at 711 or 1-800-346-4128 if you need support for hearing or blindness. Language assistance is available, free of charge. Our fax number is 801-281-6121.

    Providers may also submit a request or additional information online through our website. For more information click here.

    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:

    • An individual that has been identified with a chronic health condition or health care need that may benefit from care manager support.
    • An individual with health care needs that may want some help in making sure they care they receive is timely, appropriate and cost effective.
    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.

    • Abortion services
    • Bariatric procedures
    • Cosmetic procedures
    • Custom wheelchairs
    • Durable medical equipment
    • Home health care
    • Implants, such as vagal nerve stimulators
    • Outpatient therapies (ST)
    • Pharmacy: injectables administered outside provider's office, hospital setting, or clinic
    • Prosthetics
    • Synagis immunization
    • TMJ services
    • Transplant services: lung heart, liver, kidney, bone marrow, cornea, and the like

    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.

    Questions about Plans?

    • 6053 Fashion Square Drive, Suite 110
    • Murray, UT 84107