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Utilization Management

URAC accredited since 2001, our in-house Utilization Management (UM) Department demonstrates cost management strategies that strengthen the financial impact of our customized plans. The Utilization Management Department offers comprehensive services which provide a solution to the rising health care costs.  Our goal is to ensure the member is receiving the most appropriate/quality care, at the most appropriate time, in the most appropriate setting.  The UM Team has electronic access to all Plan Language, which we utilize when reviewing cases/claims for Medical Necessity to determine if there is a covered benefit for the admission, procedure, therapy, or treatment.  Our nurses assist in preventing high dollar claims by managing the current claim impact.

Our UM Program drove inpatient hospital days more than 30% below the PPO industry trend with our inpatient hospital management initiative.  To help provide our members with the most cost effective care, our UM Department will attempt to negotiate discounts for services deemed medically necessary that are high-cost or Out-of-Network.