Introduction | Prevention | Utilization Management | Disease Management | Case Management | Health Education Resources

Utilization Management
Right care. Right time. Right place.

By using current medical policies and clinical guidelines (Milliman Care Guidelines), Utilization Management links CareFirst, health care providers and your employees in a collaborative relationship to achieve medically appropriate, cost-effective health care. There are three phases of Utilization Management:

• Prospective Review
  The prospective review involves preauthorization. Before an employee is hospitalized, a utilization management nurse reviews the diagnosis, the proposed care and the setting to verify that the treatment plan makes sense and occurs in an appropriate facility.
  
  
• Concurrent Review
  Hospital stays that are longer than expected will receive a concurrent review. Care managers evaluate the continuing need for inpatient care, help identify the most appropriate clinical setting that will meet a patient's needs, and make recommendations on length of stay. Clinical staff also provide assistance with discharge planning.
  
  
• Retrospective Review
  Retrospective reviews occur when medical data is analyzed for complex and high-cost cases. This allows the utilization management team to determine the most successful and cost-effective treatments. Retrospective reviews also include post-service medical review and high-cost notifications to self-insured employers.

In addition, the reviews completed by utilization management also identify employees for our disease management and/or case management program who may not have taken MyHealthProfile. These highly integrated processes ensure that the right care is provided in the right setting at the right time.

Prescription Drug Programs*

The rising cost of prescription drugs continues to put pressure on health care costs. To meet this challenge, CareFirst frequently updates the preferred drug list and develops drug utilization programs with our pharmacy management vendor to promote drugs that are effective and cost efficient in order to maximize the value of your prescription drug benefit.

In addition, our Prescription Drug Web site, gives your employees tools they can use to get the most from their prescription dollars. They are able to get the latest updates to the preferred drug list, learn how to save money with generic alternatives, find participating pharmacies and much more.

For more information on CareEssentials, please contact your CareFirst BlueCross BlueShield representative.

*Available only to accounts with CareFirst prescription coverage