Utilization Management (UM) is the process of evaluating and determining coverage for and appropriateness of medical services, as well as providing any needed assistance to clinicians or enrollees in cooperation with other parties. A critical aspect of UM is attention to quality, which denotes adherence to standards and a commitment to improvement. We are committed to providing quality health care and services to ConnectCare enrollees and to assuring that our enrollees receive equitable, impartial utilization decisions in a timely manner.
The NCQA UM Certification process encompasses 16 UM standards, two standards addressing enrollee rights and responsibilities, and one in quality improvement. These requirements focus on consumer protection and improvement in services to customers including:
- involvement of appropriate UM professionals
- fair and timely medical necessity decisions
- measuring enrollee and provider satisfaction with the UM process
- respecting enrollee rights throughout UM operations
- maintaining confidentiality when conducting UM functions
Achieving NCQA UM Certification demonstrates the quality of ConnectCare's UM program. NCQA is an independent, not-for-profit organization dedicated to measuring the quality of America's health care. To learn more about NCQA, visit their Web site at www.ncqa.org.