02 — Capability · BC-1870.50
Utilization Management
Make sure members receive covered services that are appropriate and in the right setting, by reviewing requested services before, during and after care against published criteria and deciding within regulatory time limits. A provider requesting authorization is patient access.
- UM
- Utilization Review
- Medical Management
- Medical Necessity Review
In scope
- Prior authorization request intake and decisions
- Concurrent review of inpatient and post-acute stays
- Retrospective review
- Review criteria and reviewer consistency
Out of scope
- Requesting authorization as a provider (see BC-1810.40)
- Writing medical coverage policies (see BC-1870.20)
- Member appeals of review decisions (see BC-1870.40)
- Care management programs (see BC-1860.20)
Realized by · 3
- Salesforce · Health Cloudpartial via BC-1870.50.10
- Epic · Payer-Provider Exchangepartial via BC-1870.50.10
- HealthEdge · Clinical Edge Utilization Managementcore via BC-1870.50.10
Used in · 1
Build it · 1
Decomposes into · 4
- BC-1870.50.10Authorization Request ReviewReceive authorization requests by portal, fax and electronic exchange, check them against coverage criteria, offer the treating clinician a peer-to-peer discussion before a denial, and decide within the required time.
- BC-1870.50.20Concurrent Stay ReviewReview inpatient and post-acute stays while they happen, and agree the level of care and expected length of stay with the facility.
- BC-1870.50.30Retrospective ReviewReview services after they are delivered when authorization was not obtained or the record must confirm the service met coverage criteria.
- BC-1870.50.40Review Criteria & ConsistencyKeep the review criteria in use current and approved, and audit reviewers so the same request gets the same decision whoever reviews it.