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Utilization Management


Our Utilization Management (UM) Program is designed to achieve medically appropriate and cost-effective delivery of health care services to claimants within the parameters of the covered benefits.

UM activities are intended to identify the most appropriate treatment and, when possible, to educate physicians on the advantages of managing care in a medically appropriate and cost-effective manner. To this end, HCS adheres to the following principles:

  • UM decisions made by HCS are based solely on appropriateness of care and service within the scope of covered services.
  • HCS does not compensate those responsible for making UM decisions for denying coverage for medically necessary and appropriate covered services.
  • HCS does not offer its employees or delegates incentives to encourage denials of coverage of medically necessary and appropriate covered services, and does not provide financial incentives to providers to withhold covered health care services that are medically necessary and appropriate.
  • HCS emphasizes the provision of medically appropriate and cost-effective delivery of health care services to claimants, and encourages the reporting, investigation and elimination of underutilization.
  • HCS also expects that necessary services, tests, procedures or consultations will be performed in a timely manner.
  • HCS generally defines Medical Necessity/Appropriateness as those services provided by the hospital that we determine to be
    • A covered benefit under the policy
    • Appropriate for the symptoms and diagnosis or treatment of the condition, illness, disease or injury
    • Provided for the diagnosis, or direct care and treatment of the condition, illness, disease or injury
    • In accordance with accepted medical standards
    • Not solely for the convenience of the eligible person or others, and
    • The most appropriate level of medical care