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Utilization Management & Hospital Admissions

Utilization Management

Utilization Management (UM) assists members in obtaining quality health care in the most efficient and economical manner. Quartz has a utilization management program to protect members from unnecessary costs and to help Quartz be a good steward of plan resources for all members.

Utilization Management

A variety of processes are in place to evaluate the utilization and quality of health care services provided to Quartz members. All the Utilization Management (UM) programs are supported by qualified health professionals and physicians whose education, training, and experience are commensurate with the UM reviews they conduct.

The Quartz Utilization Management Team includes:

  • Medical Management
  • Behavioral Health Care Management (including AODA management)
  • Quartz Pharmacy Program

To assess the clinical appropriateness of hospital inpatient and other services, the Medical Management and Behavioral Health Care Management teams utilize clinically based decision support criteria called InterQual®.

InterQual® criteria are a set of clinical practice benchmarks used to review patient care requests for medical necessity. The criteria outline the most effective and efficient treatment for a given condition and the expected progress of the treatment plan, such as projecting the length of stay and the monitoring of care that a patient may require.

Prior authorization decisions are also made using Medical Management and Behavioral Health Care Management internally derived policies and procedures, developed using evidence-based guidelines based on national, state, and locally established standards of practice. Utilization of InterQual® criteria and evidence-based policies and procedures eliminates reviewer subjectivity, guides decisions about clinical appropriateness that support cost-effective, appropriate level of care decisions, and ensures quality of care and service.

Quartz monitors the UM decision-making processes to ensure appropriate utilization and to prevent inappropriate denials. In addition, Quartz’s Utilization Management/Technology Assessment Committee (UM/TAC) consists of plan physicians who oversee UM activities, including assessments of new technology and new applications of existing technology.

Quartz does not provide financial incentives based on underutilization or utilization management denials/decisions. All UM decision making is based on appropriateness of care and service, the local delivery system, the member’s Certificate of Coverage, and any associated benefit riders.

Medical management policies and procedures can be accessed at: Quartzbenefits.com/medpol or by calling Medical Management at (888) 829-5687. Behavioral health care management policies and procedures can be obtained by calling Behavioral Health Care Management at (800) 683-2300.

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