Spotlight on Utilization Management (UM)
Message from Tracy Mohn and Tracy Giere, Managers of Utilization Management.
Tracy Mohn and Tracy Giere oversee our Utilization Management (UM) department here at Blue Cross Blue Shield of North Dakota (BCBSND).
BCBSND operates a multi-dimensional UM Program to oversee and monitor inpatient and outpatient health care services on the precertification list provided to its members. The UM program involves prospective, concurrent and retrospective evaluation of the services provided to members. The program involves the cooperative participation of BCBSND staff, clinicians, contracted hospitals, ancillary providers and members to ensure the program is effective.
UM is designed to review services before, during or after the members care in accordance with the member’s benefit plan. Medical records and pertinent information regarding the member’s care will be reviewed (with input by peer clinical reviewers when necessary) to determine the level of coverage for a service utilizing the members’ benefits and evidence-based clinical criteria.
The UM team will be going live with the new precertification tool called Predictal this Fall. Predictal will integrate with Availity Essentials, enabling you to optimize the efficiency of your precertification submissions and reduce administrative burdens. To ensure you leverage the tool to its full capabilities when we go live this fall, we encourage you to connect with your system’s facility administrator to ensure you have access to Availity Essentials, especially if you do not have access today. More information on Availity Essentials’ functionality, registration, training tips and resources can be found on our website under Availity Essentials.
To increase efficiency for providers, BCBSND will be implementing PA Checkpoint. This tool is an enhancement on the Availity Portal which will provide real-time responses to providers to assist in determining if a given code requires precertification, is experimental or investigative, or does not require review. It also will link providers directly to the medical policies specific to the code entered, increasing efficiency for providers. All responses are tracked through Availity, and providers will receive a tracking number. The goal of this tool is to improve provider experience and provide timely responses to patient care requests.
If you have questions about UM, please contact 1-800-952-8462.
~ Tracy Mohn and Tracy Giere