What Utilization Review Services are available?
A6. For the HMO tier of our POS product, Blue Cross requires the contracted Participating Medical Group /Independent Practice Association (PMG/IPA) to have a structured utilization management program that monitors and evaluates member care and services. The utilization management functions of referral management, prior authorization, and concurrent and retrospective review are most effectively and efficiently performed at the PMG/IPA level. Blue Cross will jointly or solely perform case management as appropriate to the case management identification process. The Blue Cross UM Program is designed to provide comprehensive oversight of the PMG/IPA’s UM activities through an annual audit process. We monitor and evaluate all aspects of the care delivery system across the Blue Cross provider network. Contracted PMGs/IPAs must demonstrate that they have developed and/or adopted and implemented criteria for review of medical appropriateness. Criteria must be reviewed at least annually and as n
