We want you to utilize all the services you need to keep you as healthy as possible. However, we also want to make sure services aren’t over-utilized, which affects costs for everyone.
That’s the idea behind our Utilization Management (UM) program. Through this program, we make clinical care coverage decisions based on carefully evaluated available information.
To help you receive quality health care in an appropriate treatment setting, we provide utilization management (UM). UM includes evaluating requests for coverage by applying medically and necessary coverage guidelines (clinical criteria guidelines) to determine the medical necessity and appropriateness of the health care services under your benefit plan. These guidelines include the following:
- Prospective (Before Treatment): We determine whether a treatment is medically necessary before it begins.
- Concurrent (During Treatment): We review treatment during the course of care to determine medical necessity.
- Retrospective (After Treatment): We review treatment for medically necessity after treatment is complete.
For services and prescriptions that require preauthorization, we conduct pre-service reviews. If you are hospitalized, we review all available information in order to facilitate the transition from hospital to home, or hospital to another health care environment. Reviews are also conducted postservice, to review prescriptions and other medical needs.
Who makes utilization management decisions?
For clinical coverage decisions regarding medical services, denials are made only by board-certified physicians. For clinical coverage decisions regarding medications, denials are made only by board-certified physicians or registered pharmacists.
If you have any questions about what your specific plan covers, please read your Benefit Document or access your secure member account at mytuftshealthplan.com.