Utilization Management

By reviewing medical services and procedures to determine if they are medically necessary and appropriate, Mutual of Omaha’s Utilization Management program helps reduce unnecessary claims.  The Utilization Review Accreditation Commission (URAC) has awarded our Utilization Management program full accreditation.

Precertification Review

Mutual’s Utilization Management program offers several areas for which plan members must precertify their care.  These include inpatient confinements, selected outpatient surgical procedures, specialized home health services and supplies, outpatient high end radiology services, specialty drugs and medicines, behavioral health – inpatient care and behavioral health – outpatient care.  Our precertification reviews help you reduce claims costs by evaluating these high dollar claim expenses before a plan member’s utilization of a medical service or procedure.

Additional Utilization Management Services

In addition to precertification reviews and working in conjunction with other medical management staff members, our Utilization Management staff provides:

Concurrent Reviews – Effectively manages length of stay and medical services by monitoring the medical necessity and/or appropriateness of ongoing services

Retrospective Reviews – Determines the medical necessity for services that require precertification when a plan member fails to complete the precertification process prior to services being rendered

Discharge Planning – In coordination with Case Management, identifies plan members for whom timely discharge to less acute care is appropriate, assists the plan member in finding alternative care and addresses potential discharge needs

Referrals to Other Medical Management Programs – Recommends plan members who could benefit from our Case Management and Disease Management programs