UM Excellence

Right Care, Right Setting

Utilization management is among the most sensitive functions in health plan operations — balancing member access to needed care with appropriate oversight of medical necessity. Hetasalvation's UM team brings clinical expertise, evidence-based criteria application, and regulatory compliance to every review.

Our UM services are built on URAC-accreditable processes, InterQual and MCG criteria, and a member-centric philosophy that preserves access to appropriate care.

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UM Services

Comprehensive UM Programs

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Prior Authorization

Timely, accurate prior authorization decisions using evidence-based criteria — with automation for routine decisions and clinical review for complex cases.

PA request intake & tracking
InterQual / MCG criteria application
Auto-approval for routine services
Physician reviewer escalation
Real-time auth status portal

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Concurrent/Inpatient Review

Active management of inpatient admissions — daily census review, level of care assessment, discharge planning, and length-of-stay management.

Daily inpatient census review
Level of care determinations
Discharge planning facilitation
Peer-to-peer review coordination
LOS benchmarking & management

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Retrospective Review

Post-service medical necessity review of claims requiring clinical validation — with consistent criteria application and defensible determination documentation.

Post-service medical necessity review
Emergency admission retrospective review
Retrospective denial determinations
Supporting documentation review
Audit-ready determination records

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Case Management

Complex case management for high-risk members — coordinating care, closing gaps, removing barriers, and preventing avoidable hospitalizations.

High-risk member identification
Complex case management
NICU / transplant case management
Care plan development
Community resource coordination

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Care Transitions

Evidence-based care transition programs that reduce readmissions and ensure members receive the right follow-up care after a hospital discharge.

Discharge planning support
Transitions of care coordination
Post-discharge follow-up calls
PCP appointment facilitation
Readmission prevention programs

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UM Analytics & Reporting

UM performance dashboards — authorization turnaround times, approval and denial rates, overturn rates, and provider utilization patterns.

PA turnaround time monitoring
Approval / denial rate reporting
Peer review & overturn analysis
Top utilizers by provider / facility
Regulatory compliance reporting

Utilization Management