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Utilization Management
In health care, utilization management is the techniques and policies for checking how necessary medical treatments and services are on a case-to-case basis.
Why Is Utilization Management Important?
It helps lower costs.
Utilization management helps Blue Cross and Blue Shield of Illinois check that the care given to you is needed and effective, helping manage your health care costs.
It improves patient care.
Utilization management can help check if a service or prescription drug is helping you. This information can help BCBSIL to approve of similar treatment plans in the future.
It reduces claim denials.
Utilization management reviews can gather data about which treatments are effective and give providers information to support their treatment plans and claims.
How Does Utilization Management Work?
Reviewers with BCBSIL evaluate each patient case to know if it’s necessary to perform the medical procedures and services a healthcare specialist recommends. These reviewers use evidence-based guidelines in their analysis.
Together, your doctor and BCBSIL will perform reviews that help check how effective your treatments are before, during and after care. These reviews can include:
- Prior Authorization
- Recommended Clinical Review
- Post-Service Review
1 Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL.
eviCore healthcare (eviCore) is an independent company that has contracted with BCBSIL to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSIL.
2 Some services not requiring prior authorization may be reviewed for medical necessity before a claim is paid. Recommended clinical review (predetermination) is not a guarantee of benefits. Actual availability of benefits is based on eligibility and the other terms, conditions, limitations, and exclusions under your benefit booklet.