For Members & Families
We perform medical necessity reviews on behalf of your health plan. Here’s how the process works and how you can share additional information if needed.
What is Utilization Review?
Utilization review (UR) is how health plans check whether services are covered, medically necessary, and consistent with plan policies. Your doctor recommends care, and UR compares the request to plan rules and clinical guidelines. Final coverage is determined by your plan benefits.
1) Review
We review the request against plan policies and evidence-based criteria. Sometimes we may ask your provider for more information.
2) Determination
A decision is issued to your provider (and to you when required) with the rationale and next-step options if it’s not approved as requested.
3) Next Steps
Your provider can request a peer-to-peer, submit additional documentation, or file an appeal according to plan timelines.
Share More Information
Ask your provider to send any new clinical details that may help clarify the medical necessity of the request.
Appeals
If you receive an adverse decision, your health plan will include instructions on how to appeal and the timelines that apply. External review may be available in some cases.
We are not your treating provider and do not give medical advice. Coverage is determined by your health plan. If you have benefit questions, please contact your plan directly.