Proactive Health Management: AI analyzes utilization patterns to anticipate member needs based on clinical conditions and risk factors. Identifying trends in real time allows for early interventions, …

Healthcare utilization is the term used to describe the use or consumption of a healthcare service, procedure, device, or pharmaceutical drug for the purpose of maintaining one’s health and well …

Utilization review staff assess the patient's ongoing care, including the medical necessity and appropriateness of services being provided. ICD-10, CPT, and HCPCS codes may be used to …

NCQA’s Utilization Management (UM) standards are aligned across three programs: UM Accreditation, Health Plan Accreditation and Managed Behavioral Healthcare Organization (MBHO) Accreditation …

The objective of the Utilization Management Plan (UM Plan) is to maintain high-quality, medically necessary and efficient treatment for all patients, regardless of payment source, by ensuring that …

Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable …

This chart provides the raw data indicating reported utilization performance for PS/CS organizations irrespective of what those respondents use for the denominator of the utilization calculation.