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How we make coverage decisions for care and hospital stays

About utilization management

Utilization management (UM) is a process that helps members get the right care in the right place. This process helps us decide if certain outpatient care, inpatient hospital care or procedures are medically necessary. UM also helps us decide if the services will be covered by our members' health plans.
Decisions are based on what is right for each member based on the type of care and service. We look at standards of care that are taken from:

  • Medical policies
  • Nationally recognized clinical guidelines
  • Your health benefits
Associates, consultants or other providers are not rewarded or offered money or incentives for denying care or a service, or for supporting decisions that result in using fewer services. Your health plan doesn't make decisions about hiring, promoting or firing these individuals based on the idea they will deny benefits.
To learn more about our UM process, call us toll free, Monday - Friday, from 7:00 a.m. to 5:00 p.m. at the Member Services number on the back of your ID card (more hours may be available in your area).
If you call after normal business hours, you can leave a private message. Our staff will return your call on the next business day. Calls received after midnight will be returned the same business day. See below to learn how to get help in your preferred language.

How to get help in other languages: Want to call us, but not in English?

Free language help is available.
No matter what your preferred language is, our free interpretation service can help. Just call the Member Services number on your ID card, and ask for translation services in your preferred language.
You can also ask for the translation of written materials. TTY/TDD services also are available by dialing 711 or by contacting Customer Service. A special operator will contact us to help with your needs.
Si necesita ayuda en espaol para entender este documento, puede solicitarla sin costo adicional, llamando al numero telefonico de Atencion a clientes que se encuentra en su tarjeta de identificacion de miembro o en el folleto de inscripcion.

How to file a complaint or appeal a coverage decision

If you have a concern, or if we decide a treatment or service is not covered under your plan, you can use the complaint and appeals process to help you get your concern resolved fairly. Follow these key steps. Some of these steps must happen within a certain time frame.
Step 1: Call Member Services. We'll do our best to resolve your concern concern or complaint fairly and quickly during this first call.
Step 2: If you're not satisfied with the first response to your concern, you can file an appeal. Member Services will tell you how and let you know about any steps you must take within a certain time frame.
Step 3: If step 2 doesn't resolve your concern, you may be able to appeal further. If your plan offers a second level of appeal, we'll let you know of any specific state rules or requirements and if there are other steps you can take.
Step 4: In some cases, if benefits are denied at the final internal appeal level, you may have the right to ask for an independent external review.
You can find more details about the complaint and appeals process by calling the Customer Service number on your member ID card.