Dean Health Plan is committed to providing the best value and care to our members. Our Utilization Management Program was developed to support our commitment and ensure appropriate utilization of medical resources to maximize the effectiveness of care provided to you. This program implements a systematic and organized approach to assess, plan, implement, coordinate, monitor, evaluate, promote and improve high-quality member care.
High-quality care means the clinical management you receive is effective and appropriate, and that it is available and accessible when you need it. It also means care should be delivered in a timely manner, respectful and caring from the member's perspective, effective, safe, efficient and well coordinated over time across practitioners and settings.
Objectives of the Program
The objectives of the Program are to:
- Comply with state and federal regulations including the National Committee for Quality Assurance (NCQA).
This includes the screening and monitoring of written requests for prior authorization, referral requests for selected outpatient care and services as well as performing concurrent review of selected inpatient hospital admissions and outpatient care and services, and performing retrospective review for selected inpatient and outpatient care and services. Behavioral health care is included in these activities.
- Conduct case management of high utilization, catastrophic and complex cases, including disease management for members with targeted chronic disease states.
- Screen and monitor written referral and prior authorization requests for services both within and outside the DHP network. Monitor and evaluate the consistency of utilization management (UM) decision making.
- Coordinate care and services with non-contracted or out of network services.
- Conduct technology assessments on both new medical technologies and new applications of existing technologies.
- Meet established turnaround time standards for UM decisions.
- Participate in the evaluation of Customer and Practitioner Satisfaction measures and make appropriate improvements.
- Evaluate the appropriateness of UM criteria and guidelines for decision-making.