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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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Utilization Management

Utilization Management (UM) is the process by which we provide consistent and efficient support to the medical management activities of the plan.  
A team of UM trained nurses works collaboratively with our Medical Directors, physician advisors and network physicians to ensure that our members have access to the most appropriate level of quality care. Benefits requirements vary by group and member; please be sure to verify coverage.  
Milliman Guidelines, WellPoint Medical Polices and Clinical Guidelines, and internally developed medical technology policies are used as the supporting documentation for all UM activities. Please contact the plan for further information.  
UM Services include. 
Admission Review
Concurrent Review
Referral Management
Pre-certification of outpatient and ancillary services
Retrospective Review
Discharge Planning
Case Management
Under Utilization Protection 
We are actively committed to providing access to affordable, quality health care. In the pursuit of this goal, we are committed to ensuring appropriate service and coverage.   
All decisions regarding medical necessity, the appropriateness of care and recommendations from the utilization management staff are based on available clinical information and the appropriateness of the services planned or rendered.   
Associates and consultants are not compensated for denials or adverse determinations, nor are there performance incentives or job-related evaluation tools that encourage or provide any incentives for denials.  
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.