The process of utilization management reviews health conditions against established norms to determine if hospital admission is necessary. If admission is necessary, in-house medical staff monitor medical treatment and recovery to determine the necessity of continued inpatient care. This process is called continued stay review. Utilization management also features an early identification mechanism by which individuals are referred for case management when appropriate.

The utilization management vendor screens obstetrical patients for potential risk of complications during pregnancy. The vendor then sends educational material to high-risk patients.

A specialized unit reviews mental health and substance abuse admissions.

Some USAble groups require preadmission certification for services other than inpatient, such as outpatient surgery.

You should consult your health plan's benefit summary for more information.

Preadmission Certification

Most USAble Administrators groups require precertification or prenotification for inpatient services. Before undergoing any hospitalization, a covered person must notify the utilization management vendor listed on the back of the health-plan ID card. Some groups impose a penalty for failure to precertify.

The purpose of preadmission certification is to avoid costly unnecessary hospitalization or unnecessarily long inpatient stays. It is not, however, a guarantee of payment.

The utilization management vendor evaluates the necessity for hospitalization and monitors medical treatment and recovery to determine the necessity of continued inpatient care.