Medical management model
Our Utilization Management (UM) program uses an integrated medical management model based on the physical, behavioral, and social needs of members. The UM program, in collaboration with other departments such as Case Management and Condition Care, facilitates the delivery of the most appropriate medically necessary care to members in the most cost-effective, least-restrictive setting.
By collecting individualized data from intake information upon enrollment, historical claims data and ongoing concurrent review, we develop a predictive model that stratifies members into levels of care that determines the level of intervention. Stratification is refined and targeted to those conditions and episodes of care that are most impactful. The care plans developed based on this information are specific to a member's needs. The members’ provider(s) are also engaged in the development and execution of the plan, so the care is integrated across physical, behavioral and social spectrums.
Our member-centric care management model integrates behavioral, physical and social factors into each member’s plan of care. Our model features the early identification of needs, continuous assessment of health and a member home approach that promotes collaboration among members, family, service coordinators, provider and community resources.
We designed this approach to care management to meet the needs of Medicaid recipients.
To learn more about our Utilization Management program or our Care Management model, please see your Provider Manual or contact your provider representative.
Provider tools and resources
- Log in to Availity
- Launch Provider Learning Hub Now
- Learn about Availity
- Precertification lookup tool
- Precertification requirements
- Claims overview
- Member eligibility & pharmacy overview
- Provider manual and guides
- Training Academy
- Pharmacy information
- Electronic Data Interchange (EDI)