Components

• Educating patient, provider and employer during the episode of care
• Adopting nationally recognized and accepted utilization management criteria to determine medically indicated services at the appropriate levels
• Identifying and investigating potential quality improvement incidences and pursuance of determined quality of care or service cases
• Implementing utilization management processes (see below)

Utilization Management Processes

• Hospital/pre-admission notification on all elective or non-emergent inpatient admissions for medical/surgical care, drug and alcohol rehabilitation and physical medicine & rehabilitation
• Concurrent review to determine the appropriateness of the inpatient services (scope of care, timely discharge, cost efficient alternative care)
• Discharge planning to determine alternative care options, including outpatient services, office care, skilled nursing services, home care and community sponsored resources
• Retrospective review which compares relative rates of healthcare resource consumption among participating providers and non-participating providers
• Second opinions to ensure the application of appropriate treatment protocols
• Out-Of-Network review for in-service area care to optimize efficient utilization of services from within the provider network
• Appeals process to allow for reconsideration of original utilization management review decisions

Encouraging Cost Efficient Utilization of High Quality
Care At The Appropriate Level Of Service