Page 20 - EPO_Member_Kit

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Utilization Management
Taking The Extra Step
As an enrollee you benefit from utilization management, a key element of managed care. Our
utilization management program uses different review processes to monitor the appropriateness,
intensity and efficiency of medical care. Utilization management draws upon the proven medical
practices of doctors all over the country to ensure that our enrollees receive high-quality medical
care. The review is based on the treatment experiences of doctors throughout the nation and
occurs in a very distinct manner. Here are some ways we use utilization management:
Case management:
This is typically used in long-term care and complicated treatment plans. We
collaborate with our providers to assess, plan, coordinate, monitor and finally evaluate complex
care needs. An example of care that is managed to this extent is organ transplants.
Medical screening:
Patients benefit from a frequent screening process before services are
provided that considers whether or not suggested care is appropriate for the condition.
Retrospective care:
After care is provided, the services provided are reviewed for medical
necessity and billing practices used by the provider.
Prior authorization/Precertification:
A review process designed to assist you and your doctor in
making decisions about your medical care. We review the appropriateness of elective medical
services before they are provided, to direct you to the right specialist and to avoid duplication of
diagnostic procedures. Your doctor coordinates the medical care and is an important part of the
prior authorization process.
Prior authorization of admissions is a review process to ensure that you meet the criteria for
elective or emergency admissions before going into the hospital. In other words, all hospitals that
are contracted with us must call prior to admitting you. This service is available 24 hours a day,
seven days a week.
Many times your doctor will call and preauthorize these situations. It is your responsibility to call
and ensure that a service has been preauthorized.
Alliance’s Pledge to Enrollees
Alliance continually strives to ensure that you receive all necessary services at the appropriate
time and in the appropriate setting. All utilization management decisions are based only on the
appropriateness of care and service and existence of coverage. We do not specifically reward
practitioners or other individuals conducting utilization review for issuing denials of coverage or
service care. Furthermore, Alliance does not offer financial incentives to encourage inappropriate
underutilization of covered services.
If you have questions about these review processes, please call us. We are available for questions
around the clock. Just call us at
(313) 664-7010
or toll-free at
(888) 999-4347
. Telecommunication
services for the deaf are available by calling toll-free
(800) 956-4325
. If it is after business hours,
please leave a message and we will return your call the next business day.