Utilization Management
Ensure the effective utilization of healthcare resources
Automate prospective, concurrent, and retrospective reviews on the same information platform as other medical management activities, ensuring healthcare resources are consistently, efficiently, and effectively employed.
Referral management – Support multiple intake processes and referral sources, automatically assigning the requests to the appropriate resources or queues for evaluation.
Pre-authorization / Pre-certification – Streamline the creation of authorizations using easy-to-use, structured, clinically relevant workflows.
Auto approvals – Create business rules for automatic approvals of select services, allowing clinical resources to focus on higher value cases.
Letter generation – Automatically generate template-based provider and consumer letters to appropriately communicate the disposition of all utilization management services.
Medical review process – Give all constituents, internal and external, full visibility in the medical review process, while ensuring all tasks are accomplished on time by the correct resource.
Appeals & grievances – Structure the end-to-end appeals & grievances process, maintaining adherence to plan policy and all relevant regulatory requirements while fostering strong relationships with providers and consumers.
Embedded criteria – Embed evidence-based clinical criteria from McKesson (InterQual® Criteria), Milliman and other third-party sources directly into the application workflow, while fully supporting deployment of plan specific content in parallel.