Prior Authorization Has a New Home: Utilization Management

Prior authorizations are now under Utilization Management on our website. Utilization Management is at the heart of helping you determine coverage. It also helps our members get the right care, at the right place and at the right time. We use evidence-based clinical standards in our three types of utilization management reviews:

• Prior Authorization
• Predetermination
• Post Service Review

More Information

To learn more, see our Utilization Management web page which includes:

• Explanations of utilization management reviews
• Links to tools to manage utilization management reviews
• Links to predetermination and prior authorization code lists

Watch for additional changes in January where Utilization Management will be moved under the Claims and Eligibility menu for easier flow of information related to submitting claims. This change will include an updated link to Utilization Management.

Eligibility and Benefits Reminder

Always check eligibility and benefits for each member using Availity or your preferred vendor. This will confirm they are members, check their coverage, let you know you’re in-network for their policy and tell you if you need to request prior authorization.

If you have questions, contact your Network Management Representative.