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
Contacts
In some instances, HCS handles UM services for the claimant and in some cases the claimant’s insurer handles the UM services.
Please call HCS at 1-800-985-7777 for all UM inquiries. To discuss a non-HCS UM inquiry, the hospital must contact the claimant’s insurer.
Precertification for Workers’ Compensation
For workers’ compensation claimants, the treating physician is responsible for obtaining precertification for:
- Audiology
- Chiropractic care
- CT/CAT scan
- Durable medical equipment (DME) costing more than $500
- Electroencephalogram (EEG)
- Extended care and rehabilitation facilities
- Home health care
- Infusion therapy
- MRI
- Needle Electromyography (EMG)
- Nonemergency inpatient and outpatient hospital care
- Nonemergency surgical procedures
- Occupational therapy
- Out-of-network referrals
- Outpatient psychology and psychiatric services, including biofeedback
- Pain management services
- Physical therapy
- Podiatry services
- Second opinions
Precertification for Personal Injury Protection (PIP)
For PIP claimants, the treating physician is responsible for obtaining precertification for:
- Brain Audio Evoked Potential (BAEP)
- Brain Evoked Potential (BEP)
- Brain mapping
- Cognitive therapy
- CT/CAT scan
- DME, including orthotics and prosthetics, costing greater than $50 or rental longer than 30 days
- Dynatron/Cyber Station/Cybex
- EEG
- Extended care and rehabilitation facilities
- Home health care
- H-reflex study
- Infusion therapy
- MRI
- EMG
- Nerve Conduction Velocity (NCV)
- Nonemergency dental restoration
- Nonemergency inpatient and outpatient hospital care
- Nonemergency surgical procedures
- Occupational therapy
- Other restorative therapy
- Pain management services except those provided for identified injuries in accordance with Decision Point Review
- Physical Therapy
- Psychology and psychiatric services, including biofeedback, outpatient
- Somatosensory Evoked Potential (SSEP)
- Sonograms/ultrasounds
- Speech therapy
- Therapeutic or body part manipulation, including manipulation under anesthesia
- Thermograph/Thermography
- Videofluroscopy
- Visual Evoked Potential (VEP)
Referrals
HCS does not require physicians to complete a referral form for services as a condition for coverage.
Initial, Concurrent and Retrospective Review
- If a case manager is assigned to the hospital, he or she will review the medical record on a daily or as-needed basis.
- If an inpatient case manager is assigned to the hospital, the hospital’s Case Management or Utilization Review Department may be contacted by the HCS case manager. The hospital staff is required to provide relevant clinical information prior to discharge or, if necessary, following discharge.
- In certain cases, a retrospective review will be performed. In such cases, the hospital is required to provide a complete medical record. Charges unrelated to the diagnosis covered under the policy will be denied.
Transfer
The case manager’s approval is required for any transfer of a claimant to:
- An alternate acute facility
- An alternate level of care facility
- Sub-acute facility
- Skilled facility
- Custodial unit/facility
Case Management/Discharge Planning
Hospitals are responsible for discharge planning.
Discharge planning involving transfer to facilities should be coordinated through the claimant’s case manager. To reach an HCS case manager, please call 1-800-985-7777.