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Utilization Management

Updated on January 11, 2022

Pega Care Managementoffers a comprehensive utilization process that begins with prior authorization requests (inpatient, outpatient, referrals, and pharmacy), admission registration (notification), initial and concurrent review, discharge planning and transitional support programs, and opportunities for discussion around denials.

Configurable business rules allow for automated processes for automated authorization or pend rules or both. HL7 Admission, Discharge and Transfer (ADT) are available. Additionally, the processing of 278 receipt and response comes with the application. Pega Care Management offers integration with national clinical guideline vendors (MCG and Change Healthcare) that allow for the clinical guideline review to be integrated fully within the workflow. Service Level Agreements (SLAs) support regulatory compliance and reporting for organizations.

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Prospective review (Prior authorization)

Organizations use prior authorization for management of high cost, high utilization, or other services that require monitoring. Frequently, prior authorization has been used to control medical costs that are experienced by a health plan or provider organization. Prospective review is offered for inpatient, outpatient, referral, and pharmacy management.

Low code, stage-based development view
Shows how to create an authorization request

Initial and concurrent review

Pega Care Management provides the capability to manage care through the course of an episode. After the initial review, a concurrent review of utilization of services can be used to continue to monitor the medical necessity of coverage of services. Discharge planning starts at the time of the admission. The discharge worksheet is automatically created to support the planning at the point of admission. Documentation within the case provides centralized documentation and visibility to the patient and care team.

Retrospective review

Pega Care Management provides the ability to review services that have been received but are not yet authorized for coverage.

Integration with industry best practice clinical guidelines

Pega Care Management offers certified workflow embedded integration with third-party clinical guidelines from Change Health InterQual® and MCG Cite CareWebQI® that bring together state of the art clinical content with superior workflow capabilities. MCG’s Informed by MCG® for Disease Management integrates fully with Pega Care Management, and assessments are delivered in the same manner as internally designed assessments.

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