Utilization Management / Health Services

Physicians Plus Utilization Management (UM) program ensures the appropriate allocation of health care resources. 

UM Criteria

UM criteria are available to practitioners upon request. You may

  1. Obtain a copy of case-related criteria;
  2. Discuss UM issues or process with staff;
  3. Discuss a UM denial; or
  4. Contact a reviewer by calling the Health Services department at (608) 282-8900 or (800) 545-5015.

UM Decision Making

UM decision making is based only on appropriateness of care and service and existence of member’s current coverage. Physicians Plus does not specifically reward practitioners or other individuals for issuing denials of coverage or care. Financial incentives are not provided to UM decision makers to encourage decisions that would result in under-utilization.

UM Procedures

Medical care management procedures include prior authorization, concurrent review, retrospective review, and case management. All covered medical services are included in this program. The focus of utilization management activities include the following areas:

  • To provide access to high quality, medically necessary health care services in the most appropriate and cost-effective setting.
  • To ensure effective and efficient utilization of health care services and benefits by appropriate utilization of resources and services in the inpatient, outpatient and rehabilitative settings.
  • To document and evaluate patterns of resource utilization, including under and over utilization of services. To assist in the promotion and maintenance of high quality care through analysis and review of clinical practice.
  • To interpret data to identify areas for improvement, establish priorities, and create interventions for service and quality of care concerns. 
  • To ensure health care services are coordinated, timely, medically effective and efficient. 
  • To facilitate and coordinate heath care services for members in need of acute and chronic health care services. 
  • To educate providers and members regarding plan goals, regulatory standards, criteria used for review, and processes for providing cost-effective and quality care.
  • To meet all appropriate regulatory standards. 
  • To incorporate Physicians Plus providers’ input into the ongoing development and implementation of care management program components.