Does Leon Medical Centers Health Plans have a Utilization Management Program?
Yes. Leon Medical Centers Health Plans has a Utilization Management (UM) program to ensure that utilization decisions affecting the member’s healthcare are done in a fair, impartial and consistent manner. The UM program components are pre-authorization, concurrent review, retrospective review and case management. The UM program is designed to make healthcare services available to members in a medically appropriate, accessible, cost-effective manner. These UM program components coordinate their efforts to (a) evaluate service and care, and (b) make decisions regarding benefit coverage. The following are brief summaries of each UM program component: Pre-authorization is the process of health services being reviewed before services are approved through the referral process. Concurrent review is the process of continuous medical monitoring while the member is in an inpatient facility or receiving a plan of care. This review assures that all the days in the facility are medically appropriat
