Utilization Management Programs
Utilization management including coverage requests, inpatient hospital authorizations, emergency care
The Utilization Management (UM) Program is a component of the Clinical Operations Department and monitors both access and quality of care using nationally recognized, evidence-- based standards of care across the Medicare lines of business. All requests are assessed based on medical necessity and appropriateness of services using a hierarchy of medical evidence that includes nationally recognized criteria, such as MCG® Guidelines, the Centers for Medicare and Medicaid Services’ (CMS) definition of medical necessity and CMS National and Local Coverage Determinations, and Magellan coverage guidelines, when authorizing the delivery of healthcare services to members.
Chronic Care Improvement Program (CCIP)
Information on Mass Advantage’s CCIP program