Utilization Management

Utilization Management (UM) involves a comprehensive, systematic approach to the delivery of effective and appropriate care and services to members. It is designed to coordinate the provision of services to members; promote and assure service accessibility; provide attention to individual needs, continuity of care, and comprehensive and coordinated service delivery; provide culturally appropriate care; and assure fiscal and professional responsibility. As such, PrimeWest Health has created a Utilization Management Plan to address these areas. Components of the Utilization Management Plan provide mechanisms for reviewing, monitoring, evaluating, and improving the utilization of all covered services. This includes behavioral health services, dental services, pharmacy services, chiropractic services, and all medical services.

All UM determinations are based solely on the appropriateness of care and service and the member's coverage. PrimeWest Health does not reward practitioners or other individuals for issuing denials of coverage or care. There are no financial or other incentives for UM decision makers to encourage decisions that result in underutilization.

UM staff are available during normal business hours, Monday – Friday, 8 a.m. – 4:30 p.m., at 1-866-431-0803 (toll free). They can answer questions about specific UM cases or the details of a UM decision. If you call outside of normal business hours, you will be given instructions about how to leave a voicemail message or send a fax with your questions. UM staff will reply on the next business day.