The Priority Health Utilization Management Program

The Priority Health Utilization Management (UM) Program promotes medically appropriate, cost effective delivery of health care services provided by physicians, hospitals, behavioral health practitioners, home care agencies, PHOs/POs and other providers as appropriate.

This program applies to all dimensions of health care delivered for commercial as well as Medicaid and Medicare members of Priority Health and Priority Health Government Programs, Inc., respectively, through relationships established with employer groups and the State of Michigan.

Utilization Management Program components

The UM program includes prior authorization, utilization review, discharge, transitional care planning, retrospective review and case and disease management. Members and providers can speak to staff members regarding the UM process or decisions. Information regarding how to contact the staff members is included in newsletters and here in the Provider Manual.

Utilization Management Program criteria

The Health Management staff use these criteria to help evaluate medical necessity and appropriateness of care:

Also see:

Ensuring fair and consistent utilization decisions

Priority Health makes every effort to make utilization decisions that are fair and consistent in order to serve the best interests of our members. That is why we:

  • Make utilization decisions based only on appropriateness of care and service, as well as existence of coverage
  • Will not compensate practitioners or other individuals conducting utilization review for denial of coverage or service
  • Will not offer financial incentives or rewards for utilization decision-makers to encourage denial of coverage or service
  • Decide on coverage of new technology after comprehensive research and review by the chief medical officer and physician committees

Full program description

Get a complete copy of the Utilization Management Program description by contacting your provider performance specialist.