Utilization Management

Overview                            
Hospital and Inpatient Rehabilitation Centers
  Prior Authorization
  Skilled Nursing Facilities

 

The Utilization Management (UM) program outlines and describes MediGold's multidisciplinary, comprehensive approach to assure that members receive appropriate levels of cost-effective and quality health care services.

 

Through UM, MediGold works with providers to ensure:

  • Medical necessity of services within the plan.
  • Services are rendered at the appropriate level of care.
  • Available resources are utilized in an efficient manner in the delivery of services.
  • Adequate systems  and  resources  are  in  place  for  optimal  management  and improvement in the delivery of health services by network providers.
For more details, please see our MediGold Provider Administrative Manual at: MediGold.com/For-Providers/Tools-and-Resources/Provider-Admin-Guide


Availability of Utilization Staff

MediGold's health services department provides medical and support staff resources, as well as a medical director, to process requests and provide information for:

  • Routine or urgent authorization/pre-certification of services.
  • Utilization management functions.
  • Provider questions, comments or inquiries.

We are available 8 a.m. to 4:30 p.m. ET Monday through Friday.   Nurse Assignments

Clinical Decision-Making Process
Clinical Decision-Making Process

Urgent and Emergency Care

Urgently needed services are covered services provided in and out-of-network when such services are medically necessary and immediately required:

1.  As a result of an unforeseen illness, injury or condition; and

2.  Is not reasonable, given the circumstances, to obtain the services through network providers.

 

Emergency services are covered inpatient and outpatient services that are:

1.  Furnished by a qualified provider.  

2.  Needed to evaluate or stabilize an emergency medical condition as defined below:

 

An “emergency medical condition” is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious:

1.   Jeopardy to the health of the individual or, in the case of a pregnant woman, her unborn child.

2.   Impairment to bodily functions.

3.   Dysfunction of any bodily organ or part.

 

For emergency services:

  • Members are instructed to proceed to the nearest health care facility, whether or not that facility is a MediGold network provider. Members may contact their primary care provider (PCP) if uncertain about their clinical condition or how to proceed. The PCP may instruct the member to proceed to the nearest facility or to dial 911.
  • When a MediGold member presents to a network hospital emergency room (ER) for care and is admitted as an inpatient, the network hospital is required to notify MediGold within two business days.
  • For emergency services obtained from out-of-network providers, the member, the member’s family member or the attending physician is responsible for notifying the member’s PCP within 48 hours.
  • MediGold reserves the right to transfer members in stable condition to network providers when the transfer can take place without harm to the member. MediGold also reserves the right to retrospectively review emergency room and urgent care records and may, subsequently, determine that the care was not a medically necessary emergency or an urgently needed service. This retrospective review may occur at the point of claims adjudication and/or upon UM audit of ER/urgent care services. MediGold will consider the perception of a “prudent layperson” when reviewing urgently needed or emergency services.

 

Updated 01/2018