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Utilization Management
In health care, utilization management is the techniques and policies for checking how necessary medical treatments and services are on a case-to-case basis.
What Is Utilization Management?
Utilization management is at the heart of how you access the right care, at the right place and at the right time. It is a practice that looks at the use of medical care to make sure a service is appropriate. We use evidence-based clinical standards to ensure you get the health care you need.
There are reviews that your doctor can arrange with Blue Cross and Blue Shield of New Mexico before you get care. These reviews help figure out if a service is medically necessary. They also let you know if your health plan will cover it.
Choose a plan type below to learn more:
Why Is Utilization Management Important?
It helps lower costs.
Utilization management helps Blue Cross and Blue Shield of New Mexico check that the care given to you is needed and effective, helping manage your health care costs.
It improves patient care.
Utilization management can help check if a service or prescription drug is helping you. This information can help BCBSNM to approve of similar treatment plans in the future.
It reduces claim denials.
Utilization management reviews can gather data about which treatments are effective and give providers information to support their treatment plans and claims.
1 Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSNM to provide utilization management services for members with coverage through BCBSNM.
eviCore healthcare (eviCore) is an independent company that has contracted with BCBSNM to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSNM.
2 Some services not requiring prior authorization may be reviewed for medical necessity before a claim is paid. Recommended clinical review (predetermination) is not a guarantee of benefits. Actual availability of benefits is based on eligibility and the other terms, conditions, limitations, and exclusions under your benefit booklet.