Utilization Management

Our Utilization Management (UM) staff reviews the health care services you get, according to established criteria or guidelines. We do this to make sure it is the best care for your needs.To see what services may need prior authorization, access your member handbook in or Spanish… Coming soon.

Access to Staff

You can call the UM staff Monday – Friday from 8 a.m. to 5 p.m. Eastern Standard Time (EST):

• Staff can get messages about UM issues after normal business hours.
• Staff can email messages about UM inquiries during normal business hours, unless otherwise agreed upon.
• Staff are identified by name, title and organization name when they call about UM issues.
• Staff are available to accept collect calls regarding UM issues.
• Staff are accessible to callers who have questions about the UM process.

You can call us anytime about UM for medical prior authorization requests. We also give help to members that speak a language other than English so they can talk about UM issues or concerns. Just call Member Services at 1-855-852-7005 (TTY: 1-800-648-6056 or 711).

Any decisions we make with your health partners about the medical necessity of your health care are based only on how appropriate the care setting or services are. Humana – CareSource does not reward health partners or our own staff for denying coverage or services. We do not offer financial incentives to our staff that encourage them to make decisions that result in under-utilization. 

Review of New Technology

We will look at any requests for newly developed technology or services that Humana – CareSource does not cover now. This includes newly developed health care services, medical devices, therapies and treatment options. Coverage is based on state laws, external technology assessment guidelines, Food and Drug Administration (FDA) approval and medical literature recommendations.