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.
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.