Utilization Management
Phelps Health Medicare Advantage
Utilization Management (UM) is an important part of your overall care. UM is the evaluation and determination (decision) of coverage for and appropriateness of medical services. UM also provides needed assistance to the clinician and/or patient to ensure appropriate use of resources. The utilization review that is performed is a formal assessment of service requests, coverage criteria, and patient specific information. Utilization review can be performed before, after, or during the service. Below are some resources you may find useful.
Utilization Review Guidelines (Coverage Criteria) are used by the plan for making determinations on service requests. These guidelines can be found in your member portal.
Medical Care Coverage Decision is important. If you are new to Phelps Health Medicare Advantage, we can help ensure continuity of care for approved active courses of treatment. Please contact Customer Service at 1-855-752-3796 (TTY: 711) if you would like assistance or have questions about any of these services.