Utilization Management (UM) Criteria and Processes in Health Care

  • March 16, 2016
  • |Quartz
|
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Quartz's utilization management criteria and processes are based the team including UWMF, UW Health, Quartz and more.
What are the utilization management (UM) criteria and processes in health care? Learn more about how UM in Quartz works here.

We strive to provide members with an understanding of our medical and behavioral health management processes, including the criteria used for decision making. Our team is accountable for performing medical and behavioral health utilization management functions on behalf of Unity. Unity’s Utilization Management team is comprised of the following –

  • The UW Medical Foundation (UWMF) provides medical management services for all members.
  • UW Health – Behavioral Health Care Management provides behavioral health and alcohol and other drug abuse (AODA) management services for all members.
  • Unity Health Insurance provides utilization management for chiropractic services.
  • The UW Health Pharmacy Benefit Management Program provides comprehensive pharmacy services for all members receiving prescription benefit coverage through Unity. Additionally, medication utilization management services are provided for selected medications covered under the medical benefit for all members.

Our medical management staff works to ensure patients receive consistent and fair benefit determinations within their insurance plans. Providing reliable and reasonable determinations requires the use of clinical decision criteria in conjunction with individual case consideration. UM decision making is based only on appropriateness of care and service and existence of coverage. Unity does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

Initial decisions for medical and chiropractic utilization management are based on condition-specific criteria supported by the nationally recognized McKesson’s InterQual Criteria. InterQual is an essential tool that assists health care organizations to balance cost and quality across the continuum of care. InterQual Criteria assists in determining if the proposed services are clinically indicated, provided at the most appropriate setting and level of care and whether further evaluation is required. UWBH utilizes the Mihalik Group Medical Necessity Manual for Behavioral Health as the criteria tool in making decisions regarding the appropriateness of behavioral health services. UW Health – Behavioral Health Care Management uses the American Society of Addiction Medicine-Patient Placement Criteria for the Treatment of Substance-Related Disorders/Second Edition as a criteria guide for determining care related to alcohol and other drug abuse.

Unity’s internal policies, developed with the assistance of Unity practitioners, are utilized as an additional source of decision-making criteria to evaluate medical care. Our internal policies serve as guidelines to minimize subjectivity, direct decisions regarding clinical services and to ensure quality care.

The UW Health Pharmacy Benefit Management Program uses internally derived criteria specific to each individual drug requiring prior authorization. The criteria are developed, approved and adopted by a committee of pharmacists and physicians from Unity’s provider network.

For utilization management inquiries, assistance, or to request a free copy of UM criteria, please contact the medical, behavioral health or pharmacy management personnel listed below. Staff is available Monday through Friday during normal business hours (8 a.m. to 5 p.m.). UM staff can also receive inbound communication after normal business hours.

If you want to discuss a medical necessity determination that has been made or would like to request reconsideration on behalf of a member, please contact Unity’s Member Advocates at 800.362.3310. Unity conducts a formal appeal process guided by state and federal laws as well as the National Committee for Quality Assurance (NCQA) guidelines to address all member reconsideration requests. The reconsideration process may involve medical specialty consultation and may include consideration by an independent review board.

UMStaff

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