Welcome to our Utilization Management and Program Criteria page. Here, you’ll find essential information about how we ensure that our services are used effectively and align with our program standards.

Utilization Management (UM)

Our Utilization Management program is designed to optimize the quality of care while controlling costs. Through UM, we assess the necessity, appropriateness, and efficiency of healthcare services and procedures. This process involves:

  • Pre-Authorization: Before certain treatments or services are provided, we review requests to ensure they meet our clinical guidelines and benefit criteria.
  • Concurrent Review: During the course of ongoing treatments, we monitor progress and adjust care plans as needed to ensure they remain aligned with clinical best practices.
  • Retrospective Review: After services have been rendered, we evaluate the care provided to confirm it met the required standards and identify areas for improvement.

Program Criteria

Our program criteria outline the specific standards and guidelines used to evaluate healthcare services. These criteria are developed based on:

  • Evidence-Based Medicine: We rely on the latest research and clinical evidence to ensure our criteria reflect the most effective and safest treatments.
  • Clinical Practice Guidelines: Our criteria are aligned with widely accepted guidelines from reputable medical organizations to promote best practices.
  • Regulatory Requirements: We adhere to industry regulations and standards to ensure compliance and maintain high-quality care.

How It Works

  1. Service Request: Providers submit requests for services or treatments that require review.
  2. Assessment: Our team evaluates the request against our criteria and guidelines.
  3. Decision: We provide feedback on approval, denial, or any additional information needed.
  4. Follow-Up: We monitor the outcomes and make adjustments to our criteria as needed to ensure continuous improvement.

Why It Matters

Effective utilization management helps:

  • Enhance Quality of Care: By ensuring treatments are appropriate and effective.
  • Control Costs: By preventing unnecessary or inappropriate services.
  • Improve Patient Outcomes: Through evidence-based decision-making and efficient care delivery.

For more details or to submit a request for review, please contact our Utilization Management department or use our online portal. We are committed to providing the highest level of care while ensuring efficient and responsible use of resources.

Exit Popup

Demo Description


Wait! Before You Go...

We noticed you're about to leave Healthy Mississippi, Inc., a secure website dedicated to Medicare Advantage information and education.

Disclaimer:
By leaving this site, you will be directed to an external website that is not affiliated with Healthy Mississippi, Inc., and/or may not be affiliated with Medicare Advantage information. Please be aware that the site's security and privacy policies may differ from ours.

If you have any questions or need assistance, please don't hesitate to reach out.

This will close in 0 seconds

Skip to content