Participating providers can now check for codes that require prior authorization via our Online Prior Authorization Search Tool.

The UM staff is available to discuss specific cases or UM questions by phone by calling 1-800-441-5501(Medicaid), 1-844-645-7371 (Comprehensive Long Term Care), or 1-844-528-5815 (Florida Healthy Kids); TTY 711 from 8:00 a.m. to 7:00 p.m. Eastern. UM Staff is available on holidays and weekends by voice mail and fax.

Utilization management is a system for reviewing eligibility for benefits for the care that has been or will be provided to patients. The UM department is composed of:

  • Preauthorization
  • Concurrent review
  • Case management

Medical necessity is based upon clinical standards and guidelines as well as clinical judgment. All clinical standards and guidelines used in the UM program have been reviewed and approved by practicing, participating physicians in our network. You can receive a copy of our clinical standards and guidelines by calling us at 1-800-441-5501 from 8:00 a.m. to 7:00 p.m. Eastern Time.

The medical director makes all final decisions regarding the denial of coverage for services when the services are reviewed via our UM program. The provider is advised that the decision is a payment decision and not a denial of care. The responsibility for treatment remains with the attending physicians. The medical director is available to discuss denials with attending physicians and other providers during the decision process. Notification includes the criteria used and the clinical reason(s) for the adverse decision. It includes instructions on how to request reconsideration as well as a contact person’s name, address and telephone number.

The policy on payment for services helps ensure that the UM decision-making process is based on consistent application of appropriate criteria and policies rather than financial incentives.

  • UM decisions are based only on appropriateness of care and service and the existence of coverage
  • We do not reward practitioners, providers or other individuals conducting utilization review for issuing denials of coverage or service care.
  • The compensation that we pay to practitioners, providers and staff assisting in utilization related decisions does not encourage decisions that result in underutilization or barriers to care or service.

If you have questions, please contact your Provider Relations representative.