Utilization Management


  The Right Care at the Right Time in the Right Setting.     Mid Atlantic Health Solutions offers proactive utilization management by evaluating the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the health benefits plan. Our services are conducted telephonically, at the national level, and under the supervision of our Medical Director while utilizing evidence-based, nationally recognized criteria. Inpatient stays are addressed through pre-admission review for appropriateness and concurrently for continued stay needs and transition management to the right level of care. Outpatient services requiring preauthorization as defined by the health plan are reviewed prospectively for appropriateness in order to reduce unnecessary surgical procedures and diagnostic tests while keeping the member’s health and safety paramount. Retrospective reviews are conducted in cases of emergent admissions or to determine the medical necessity of services provided when the health plan’s pre-authorization process has not been followed.

Mid Atlantic Health Solutions has received full accreditation in Health Utilization Management (HUM) by URAC since 2006.  URAC, an independent, nonprofit organization, is a well-known leader in promoting healthcare quality through its accreditation, education, and measurement programs.


Our state of the art Utilization Management software system coupled with the use of nationally recognized utilization criteria and experienced health professionals yields a service model that is measurable against industry utilization standards. The ability to identify potential large cases in this process allows the health plan to be better aware of pending financial impact as well as to identify trends in diagnostic groupings for development of its population management strategies.

Mid Atlantic Health Solutions is able to efficiently track and report on utilization patterns within a health plan. Our services offer value and quality to our customers whether they are members of the health plan or the health plan themselves.


More about URAC. URAC offers a wide range of quality benchmarking programs and services that model the rapid changes in the healthcare system and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in establishing meaningful quality measures for the entire healthcare industry. For more information, visit www.urac.org.