Section 6 – UTILIZATION MANAGEMENT PROGRAMS
- 6.1 ELEMENTS OF THE UTILIZATION MANAGEMENT PROGRAMS
- 6.2 ADMINISTRATION OF THE UTILIZATION MANAGEMENT PROGRAMS
- 6.3 RESTRICTIONS AND LIMITATIONS OF THE UTILIZATION MANAGEMENT PROGRAMS
- 6.4 PRECERTIFICATION REVIEW
- 6.5 REQUEST FOR REVIEW OF DENIAL OF BENEFITS BASED ON PRECERTIFICATION REVIEW
- 6.6 CONCURRENT (CONTINUED STAY) REVIEW
- 6.7 REQUEST FOR REVIEW OF A DENIAL OF BENEFITS BASED ON CONCURRENT REVIEW
- 6.8 RETROSPECTIVE REVIEW
- 6.9 CASE MANAGEMENT
The Plan pays benefits only for Medically Necessary Services. The following procedures are designed to assist the Plan in determining Medical Necessity before you receive health care services.
Purpose of the Utilization Management Programs
Your Plan is designed to provide Participants with financial protection from significant health care expenses. The development of new medical technology/procedures and the ever increasing cost of providing health care present a challenge to maintaining a high level of benefits. To enable the Plan to provide coverage in a costeffective way, the Plan has adopted Utilization Management Programs designed to help control increasing health care costs by not paying benefits for services that are not Medically Necessary. By doing this, the Plan
is better able to continue to maintain its level of benefits.
If you follow procedures of the Utilization Management Programs, you may avoid some out-of-pocket costs. If you don’t follow these procedures, the Plan provides reduced benefits, and you will be responsible for paying more out of your own pocket.