The Priority Health Utilization Management Program

The Priority Health Utilization Management (UM) Program supports the delivery of health care services provided by all qualified health care professionals aligned with evidence-based standards of care. This applies to all dimensions of healthcare delivered to our Commercial markets, as well as our government programs, federal and state sponsored health plans. 

Utilization Management Program components

The UM program includes prior authorization, utilization review, discharge planning, transitions of care, outpatient care management, integration of medical and behavioral health and retrospective review. Members and providers can speak to staff members regarding the UM process or decisions. Information regarding how to contact staff members is included in written communications, 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 or reward practitioners or other individuals conducting utilization review for denials of coverage  
  • Will not offer financial incentives or rewards for utilization decision-makers to encourage decisions that result in underutilization
  • 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.