How we make choices on care and services
Sometimes, we need to make choices about how we pay for care and services. This is called Utilization Management (UM).
Our UM program:
- Looks at what, when and how much of our services are medically needed.
- Always strives for the best possible health outcomes for our members.
Our UM program does not:
- Tell doctors to withhold or give you fewer services limiting or denying care.
- Stop certain people from getting services.
- Reward doctors for limiting or denying care.
Getting in touch with our Utilization Management staff
Some Wellpoint services and benefits need prior approval. This means your provider must ask Wellpoint to approve the services they want you to have. Services that don't need approval are:
- Emergency care
- Care needed after a hospital stay
- Our Utilization Review team looks at approval requests. The team decides if:
- The service is medically needed.
- The service is one that is included in your Wellpoint benefits.
What should you do if Wellpoint won't approve care you think you need?
You or your provider can ask us to take another look. We'll let you and your provider know when we get your request.
You can ask us to take another look at services that:
- Are not approved.
- Have been limited in the amount or length of time from what was requested.
Do you have questions about an approval or a denial you got?
Call Member Services at 833-707-0867 (TTY 711). Our Utilization Review team or your Case Manager can help answer your questions.