Posted June 25, 2021 (Updated Aug. 4, 2021)
This notice has been updated to clarify that this material focuses primarily on commercial, non-HMO/non-delegated utilization management processes.
We’re continuing to refine our Utilization Management section to help ensure the content is both useful and easy to use. This month, we added a new resource that presents the information in an interactive way.*
Our new Utilization Management: Medical Director Video includes an introduction from our Chief Medical Officer, Dr. Derek Robinson, followed by four short videos from other members of our Medical Director team.
- Choose from a menu of four topics: Terminology Overview, Intake Process, Peer-to-Peer Process, Appeals.
- View one or all of the videos, in any order.
- If you have questions or feedback on the video or other website resources, there’s a link to a survey.
We appreciate the care and services you provide to our members. We know you’re busy and we value your time. We hope you’ll find our new video helpful.
*The information in this section does not apply to delegated commercial HMO and Medicare Advantage HMO.
Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. Certain employer groups may require prior authorization or pre-notification through other vendors. If you have any questions, call the number on the member's ID card. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.