Utilization Management
We use evidence‑based clinical guidelines, including MCG, to help make utilization management decisions. Some guidelines are proprietary and cannot be posted publicly. Members and providers may request the criteria used for any specific decision.
Utilization Management Overview
Utilization management is the process we use to make sure health care services are safe, effective, medically appropriate and consistent with your health benefits. Our goal is to support high quality care while using evidence‑based standards and current clinical knowledge.
Utilization management decisions are based on your benefit coverage and medical need. We do not reward staff or decision makers for denying or limiting care.
Clinical Guidelines Used in Decision Making
We use nationally recognized, evidence‑based clinical guidelines to support utilization management decisions. This includes guidelines developed by MCG and other trusted clinical sources.
These guidelines help ensure decisions are consistent, fair and based on current medical evidence. They are reviewed regularly and updated as new information becomes available.
Because some guidelines are proprietary, we cannot post the full criteria on this website.
How Decisions Are Made
Each request for services is reviewed by trained clinical staff using your benefit coverage and applicable clinical guidelines.
When needed, a licensed medical professional reviews the request to ensure it meets medical need standards. Decisions are based on your individual medical condition and clinical information provided by your health care provider.
Utilization management decisions are not based on cost alone.
Services That May Require Review
Some services may require approval before they are provided, during treatment or after services are completed. These may include certain hospital stays, procedures, imaging services and specialty treatments.
The exact requirements depend on your health plan and benefit coverage. Member Services or Care Management can help you understand whether a service requires review.
Decision Timeframes
We follow required timeframes when making utilization management decisions.
Urgent requests are reviewed as quickly as your condition requires, with the majority completed within 3 business days’ time.
Standard requests are reviewed within established timeframes of 7 business days or less.
If we need additional information to decide, we will reach out and let your provider know.
Member Rights and Requests
You or your provider may request:
- An explanation of how a decision was made
- The clinical criteria used for a specific decision
- Information about the appeal process
Requests can be made by phone, mail or through member services.
Appeals and Grievances
If you disagree with a utilization management decision, you have the right to appeal. We clearly explain appeal rights in all decision notices.
You may also file a complaint if you have concerns about the utilization management process.
Commitment to Fair and Ethical Review
Our utilization management program is designed to support appropriate care. Staff making utilization management decisions are not financially rewarded for denying coverage or reducing services.
We are committed to treating members and providers with respect and fairness.
If you have any Utilization Management questions, please direct them to Care Management or Member Services.
If you disagree with a utilization management decision, you have the right to request a review or file an appeal.
You can also learn more about your complaint and appeal rights in your plan documents.
You have the right to receive information about how decisions are made and to voice complaints or appeals without penalty.
Utilization management decisions are based on your specific benefit coverage.
To view your plan details and services covered:
If you have questions about prior authorizations, coordination of care, or decision explanations, contact Care Management.
Phone numbers and hours are listed on the Contact page.
GHC‑SCW is accredited by the National Committee for Quality Assurance (NCQA) and follows national standards for utilization management and quality improvement.
Information on appeals, member rights and benefit coverage is available throughout this website and linked above for your convenience.