6.1 ELEMENTS OF THE UTILIZATION MANAGEMENT PROGRAMS
- Precertification Review: Review of Plan benefit coverage of proposed health care services before the services are provided (except in the case of emergency hospital admissions, where review must be sought within 72 hours after admission);
- Concurrent (Continued Stay) Review: Ongoing assessment of the Plan benefit coverage of health care services as they are being provided, especially (but not limited to) inpatient confinement in a Hospital or specialized facility;
- Retrospective Review: Review of health care services after they have been provided;
- Case Management: A process whereby the Participant, the family, Physician and/or other providers, and the Trust work together under the guidance of the Plan’s independent Utilization Management Organization to coordinate Plan benefit coverage of a quality, timely and cost-effective treatment plan. Case Management services may be particularly helpful for Participants who require complex, high-technology medical services and who may therefore benefit from professional assistance to guide them through Plan benefit coverage.