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– A doctor, health care professional or health care facility licensed, certified or accredited as
required by state law.
– Preapproval from a PCP for specialty care. Referrals are usually paperless and must follow
your health plan’s guidelines.
Self-Funded HMO
– Health plan coverage that is designed to look and feel like a health maintenance
organization (HMO), but the coverage received for medical, drugs and other services is paid for by the
plan sponsor’s general assets (operating funds) as opposed to being provided through an insurance
Skilled Nursing Care
– Services from licensed nurses in your own home or in a nursing home.
Skilled care services are from technicians and therapists in your own home or in a nursing home.
– A doctor specialist focuses on a specific area of medicine or a group of patients to
diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-doctor specialist
is a provider who has more training in a specific area of health care.
Step Therapy
– A type of prior authorization for some prescription medications. With step therapy,
in most cases, members must first try using certain less expensive medications that have been
proven effective for most people with the same condition before the member can get a similar, more
expensive brand-name drug covered.
Third Party Administrator (TPA)
– A plan administrator that provides customer service, as well as
authorizations, disease management and other programs for the delivery of a health plan.
UCR (Usual, Customary and Reasonable)
– The amount paid for a medical service in a geographic
area based on what providers in the area usually charge for the same or similar medical service. The
UCR amount sometimes is used to determine the allowable amount.
Urgent Care
– Care for an illness, injury or condition serious enough that a reasonable person would
seek care right away, but not so severe as to need emergency care.
Utilization Management
Utilization Management (UM) is the method by which we make sure our members get quality care.
This means getting the right care at the right time in the right place. We do this by using different
review processes at different stages of your care. UM utilizes proven medical practices from doctors
across the country and applies these practices when reviewing your doctor requests.
Case Management –
Used in long-term care and difficult treatment plans. We work with your doctors
to measure, plan, coordinate, monitor and review complex care needs.
Medical Screening –
A regular screening process before services happen. This looks at whether the
suggested care is right for the condition.
Retrospective Care –
A review of the services after they are provided for medical necessity and the
provider’s billing practices.
Prior Authorization/Precertification –
A review step to help you and your doctor in making choices
about your medical care. We review the appropriateness of elective medical services before they are
provided to lead you to the right specialist and to avoid copying of diagnostic treatments. Your PCP
manages the medical care and is an important part of the prior authorization process.
Prior authorization of admissions is a review process to make sure that a member meets the criteria for
elective or emergency admissions before going into the hospital. All hospitals that are contracted with us
must call to let us know about your admission. This service is on hand 24 hours a day, 7 days a week.
Pledge to Members
We continually strive 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, your health plan does not offer financial incentives to encourage
inappropriate underutilization of covered services.
If you have questions about these review processes, please call Customer Service at
(866) 766-4709
If you are deaf, hard of hearing or speech impaired, please use our TTY/TDD line at
(800) 649-3777
After business hours, please call and leave a message. We will return your call the next business day. If
needed, we can call on your behalf or connect you with other departments to answer your questions.