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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 our 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
HAP 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, HAP does not offer financial incentives to encourage inappropriate
underutilization of covered services.
If you have questions about these review processes, please call us at
(800) 422-4641
.
Telecommunication services for the deaf and hard of hearing are available by calling
(800) 649-3777
.
If it is after business hours, please leave a message and we will return your call the next business day.