Utilization management: prioritizing appropriate care and transparency

As a healthcare provider, staying informed about the utilization management (UM) process is crucial for optimizing patient care and streamlining administrative functions and claims submissions. This comprehensive guide details submission methods, necessary documentation, and contact information, ensuring you have the resources to facilitate approvals efficiently.

Support and communication

We have staff available to help with UM issues Monday through Friday, during regular business hours for inbound collect or toll‑free calls. We can also receive fax communications after regular business hours. Phone and fax number options are detailed below. Messages will be returned within one business day. When initiating or returning calls, our staff will identify themselves by name, title, and organization name. TDD/TTY and language assistance services are available for members as needed at no cost.

You can request a free copy of our UM criteria from Provider Services at 800‑450‑8753. You can also call this number to discuss a UM denial decision with a physician reviewer. Our Medical Policies and UM criteria are available on our provider website.

Preapprovals

You can submit preapproval requests by:

• Using the Availity Essentials Authorization application. Log in to Availity Essentials and select Patient Registration > Authorizations and Referrals. You can also access information previously mailed or faxed anytime in Availity Essentials.
• Faxing 800‑964‑3627.
• Calling 800‑450‑8753.

We are staffed with clinical professionals who coordinate our members’ care and are available 24/7 to accept preapprovals. Secure voicemail is available outside of business hours. A clinical professional will return your call within the next business day. Our staff will identify themselves by name, title, and organization name when initiating or returning calls regarding UM issues.

Our UM decisions are based on the appropriateness of care and service and existence of coverage. We do not specifically reward practitioners or other individuals for not approving coverage. We also do not offer financial incentives for UM decision‑makers to encourage decisions resulting in underutilization.

What if I need assistance?

If you have questions about utilization decisions or the UM process, call Provider Services at 800‑450‑8753, Monday through Friday from 8:30 a.m. to 5:30 p.m. ET. You can also use Chat with Payer from Payer Spaces on Availity Essentials.