Utilization Management
An appropriate peer reviewer (Medical Director, Pharmacist, or Associate Clinical Director) is available to discuss any Utilization Management process, authorization, or denial by calling Customer Service at 1-800-440-1561. Relevant policies and clinical criteria are available upon request.
Prior Authorization Review is the process of reviewing certain medical, surgical, and behavioral health services to ensure medical necessity and appropriateness of care are met prior to services being rendered.
- Clinical Coverage Criteria (help Utilization Management decide medical necessity)
- Clinical Practice Guidelines (help providers determine what treatments to use)
- Pre-existing condition overview for clinic staff
- Authorization for Release of PHI
- 2012 Prior Authorization List
- Prior Authorization Form
- 2011 Capped Rental List
- 2011 Benefit Grids