Transcription of Provider Manual Section 5.0 Utilization Management
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Provider Manual Section 5.0 Utilization Management
Provider Manual Section Utilization Management Table of Contents Utilization Management Review Criteria Authorization Requirements Retrospective Authorization Denials Prior Authorization for Members with Medicare / Tricare / Other Carrier Retrospective Authorization Inpatient Skilled Nursing Facility Page 1 of 8. Utilization Management Utilization Management Utilization Management (UM) is the evaluation of the medical necessity, quality, appropriateness and efficiency of the use of health care services, procedures and facilities under the provisions of the applicable health plan benefits.
Page 5 of 8 Urgent - Emergent Admission: Within one business day of the admission The UM Department will accept the hospital’s or the attending physician’s request for prior
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