Utilization Management

As a health plan, you review prior authorization and precertification requests from providers: evaluating whether proposed services meet medical necessity criteria per your medical policy, clinical guidelines, and coverage determinations. You apply medical policies (often hundreds of policies covering specific procedures, drugs, devices, and services), manage the clinical review queue, issue approvals, denials, and requests for additional information, and process appeals (including external independent review). Turnaround time requirements (urgent vs. standard, state-specific timelines) create operational pressure. CMS and state regulatory focus on prior auth burden is intensifying.