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Utilization Management

Meritain Health’s Utilization Management program meets the medical needs of members while protecting the cost-effectiveness of our clients’ benefits plans. We facilitate all steps in the utilization review process—from initial provider or patient contact through criteria application, evaluation and recommendation.  The program is URAC-accredited through American Health Holding—Meritain Health’s sister company through Aetna—and is based on three basic concepts:

 

  • Timely review and determination of clinical eligibility for coverage
  • Determination of the appropriate inpatient length of stay
  • Identification of potential case management and disease management referrals

The philosophy of our precertification process is based on the premise that early intervention can lead to claims cost reduction. Through this process we work to ensure procedures are medically appropriate, assign a length of stay, ensure the location of service is appropriate and identify potential "high-risk" cases. High-risk cases can be forwarded to our case management or disease management programs for further review. If we identify these high-risk cases early, we can begin to actively manage members earlier, greatly increasing our potential for cost savings.