Utilization Management

CFMC’s utilization management program contributes to making excellent, accessible health care affordable. Our program combines the expertise of our medical officers, physician advisors, and nurse reviewers to ensure that every person receives the right care every time. Our utilization management program’s accreditation by URAC demonstrates our commitment to quality and accountability.

Our nurse reviewers use nationally accepted, evidence-based screening criteria, clinical experience, effective decision support tools, and standardized processes to conduct all utilization review requests:

• Inpatient services
• Outpatient services
• Long term care
• Behavioral health
• Durable medical equipment
• Pre-admission review
• Concurrent review
• Retrospective review

We have an established network of nearly 150 credentialed physician reviewers in every medical specialty to review cases that do not meet our screening criteria. Our annual requirements for recredentialing exceed our own quality improvement organization requirements. Our automated, physician reviewer selection process ensures a match of a “like” physician reviewer to the physician provider. CFMC’s internal quality control process guarantees that our physician and non-physician reviewers provide evidence based, unbiased review of the case.

We also offer an appeal process for patients or providers. Our process uses a board-certified physician reviewer in the same specialty, not involved in the initial review decision, to conduct the appeal consideration.

Our in-depth knowledge and experience in utilization management ensure that the health care services provided were necessary, appropriate, and effective.

Contact Nancy Borgstadt, Director of Review Services at 800.950.8250 ext. 3153 or email Nancy at nborgstadt@cfmc.org.