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15 11/2005
Utilization Management
Participating hospitals are responsible for complying with BCBSGa/BCBSHP Utilization
Management (UM) programs. Our Utilization Management program represents and
reflects an ongoing, comprehensive, integrated and dynamic system of activities and
associates which exists to manage and coordinate access to and the delivery of health
care services; these processes also look for opportunities to improve the quality and
delivery of care and services.
The criteria used by BCBSHP and BCBSGa for Utilization Management decisions are
based on Milliman Care Guidelines and are used for the management of inpatient care
and ambulatory management. Clinical criteria are available to all members and
providers upon request. All criteria and guidelines are reviewed at least annually and
approved by the Medical Management Committee.
BCBSGa/BCBSHP’s UM Program consists of the following components:
Program Components
• Preauthorization Review to determine benefits available under the member’s
Membership Agreement for outpatient surgical and diagnostic procedures.
• Preadmission Review to review an inpatient hospital stay to determine coverage
under the member’s Membership Agreement.
• Concurrent Review to evaluate a member’s coverage under the terms of the
Membership Agreement for continued inpatient hospital stay.
• Discharge Planning to evaluate a member’s coverage under the terms of the
Membership Agreement for health care services for a member after discharge from
an inpatient setting.
• Case Management to coordinate and facilitate services and benefits members
receive to ensure they seek and receive appropriate and necessary care to
minimize duplication of services, tests and costs and to maximize benefits
available under their Membership Agreement.