Utilization review

Utilization review ensures that our members receive consistent, equitable care. Clinical professionals working within their specialties make care decisions based on our clinical practice guidelines and make referral decisions based on our clinical review criteria.

For more information, see our Clinical guidelines and Clinical review criteria.

During utilization review, we apply predefined criteria to pre-service, concurrent, and post-service requests. There are three kinds of reviews.

Pre-service review
The Mental Health Access Center staff, Pharmacy Help Desk, or Review Services initiates pre-service reviews when coverage determination requests are received for care that has not yet been received.

Concurrent review
If a prior coverage determination needs an extension, a concurrent review is initiated to consider the continuing need for coverage of outpatient care, hospital (or inpatient) care, or skilled nursing facility (SNF) care.

Post-service review
If scheduled, nonemergent-services coverage requests are received following the delivery of care, a post-service review is conducted to determine eligibility for coverage.