Universal Health Care Utilization Management
The Utilization Management Department is compromised of the following areas:
- Pre-service determination
- Concurrent Review, including hospitals and SNF's
- Case Management/Disease Management
The UM department normal business hours are Monday through Friday 8 a.m. to 5 p.m.
These hours are for routine pre-service and other utilization functions.
Telephone: 866-616-6398
Fax number: 866-420-4842 (pre-service determinations) or
800-889-6745
(concurrent review)
Web site: www.univhc.com
Clinical Criteria for UM Decisions:
UHC utilizes nationally recognized criteria to determine medical necessity and clinical
appropriateness. Criteria may also be developed by UHC based upon a review of literature
and government regulations in collaboration with the Medical Director. The Medical
Advisory Committee, consisting of local practicing physicians, approves all criteria
annually, or as indicated. Criteria utilized are consistent with clinical guidelines.
UHC adapts procedures for applying criteria to meet individual member needs and
local medical practice. The Provider Manual includes the criteria utilized. Practitioners
may also request the criteria from the UM Department. UHC’s Medical Director,
is available during normal business hours to discuss a denial case with the treating
or attending practitioner; and can be contacted by calling the UM department number
given above.
Case Management:
This program is designed to ensure that health care resources are utilized in a timely, cost effective manner
to achieve optimal wellness for the member. Providers are able to refer members or members may self refer.
Possible candidates for the Case Management Program include members with multiple chronic illnesses,
multiple admissions, trauma, AIDS, organ transplants, high-risk neonates or members needing specialty health care.
Disease Management:
The purpose of the Disease Management Program is to promote awareness of the
disease process and the medical management of selected diseases to members through education and monitoring of their conditions.
Providers are able to refer members or members may self refer.
The Disease Management Program is available for members with a diagnosis of CHF, COPD, Diabetes,
HTN, Pediatric Asthma and wound care management.
Fall Prevention Program:
The goal of this program is to encourage awareness
and provide fall prevention safety tips. Providers are able to refer members or members may self-refer.
This program is available to all Masterpiece members with a history of a fall related injury,
or who are deemed to be at risk based on their Health Risk Assessment Questionnaire.
To refer a member to any of the above programs, please contact
the Case/Disease Management Department at 866-616-6398.
Medication Therapy Management:
UHC offers a medication therapy management (MTM) program at no additional cost to members who have multiple medical conditions,
who are taking many prescription drugs, and who have high drug costs.
The program was developed and is maintained by our pharmacy benefits management partner (PBM). The PBM employs pharmacists who review
prescription records for all of our members looking for opportunities to improve. We use the program to help us provide better coverage
for our members. For example, MTM helps us make sure that our members are using appropriate drugs to treat their medical conditions and
helps us identify possible medication errors. We look for opportunities to use generic medications rather than brand name drugs to make
it easier for our patients to afford their medications. If problems are encountered the information is shared with our case management
staff who work with you to correct the problem. Our PBM will be contacting a sample of our membership during 2009 who meet specific criteria.
We then look forward to your cooperation in working with us to maximize your pharmacy experience.