Utilization Management (Precertification)

Utilization Management (Precertification)

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Our “patient-centric” utilization management program offers comprehensive services unlike other UM companies. All participants, providers, and employers/TPAs engage with a Precertification Nurse. We utilize medical review criteria guidelines from national health insurance providers, Apollo and McKesson to make medical determinations. Our Medical Director oversees this program and provides medical decision-making as appropriate.

Precertification of Medical Necessity

We offer precertification for “Medical Necessity” for:

  • Inpatient admissions (acute care hospital, rehabilitation and skilled nurse facility)
  • Outpatient services and surgery
  • Diagnostic testing ( CT scans, MRI, MRA, PET scans)
  • Chemotherapy
  • Radiation therapy
  • Dialysis
  • Pain management services
  • Durable medical equipment (DME) over $5,000

Participant Engagement & Network Participation

Our Precertification Nurses actively involve the participant and discuss the precertification case with them. We check network participation and immediately notify the participant if their provider is out-of-network. We then steer them to a high-outcome, cost-effective, in-network provider using our MAP® program.

Participant Outreach & Follow-up

Our Precertification Nurses reach out to participants and follow up with them after inpatient admissions, some minor surgeries, and diagnostic tests. A post-discharge follow-up is incorporated to help the participant make a smooth transition from the inpatient setting to the home. Using MAP®, we also verify that the medical provider assigned upon discharge is participating within the participant’s network.

Referral to Case Management

Our Precertification Nurses determine if the participant needs Case Management services, based on diagnoses, projected costs, and complexity, and make referrals as appropriate.