Review Care Requests

The Health Cloud Utilization Management features let you work with plan members and contracted medical providers to interpret, administer, and explain the medical policies of the health plan. You can influence member care decision-making via case-by-case review of the appropriateness of care before it is provided.

Note As you complete each step in this process, you can update the stage indicator to show what has been done and what remains to be done. Select the relevant stage and click Mark Status as Complete.

1. Gather Medical Information
   When a request is received for a plan member, clinical professionals and support staff gather and review the member's medical information from the provider. Health Cloud puts all the information in one convenient place for you to work with.
2. Determine Medical Necessity
   Review the drugs, devices, procedures, treatment plans, or other therapies and decide whether each is essential for addressing the patient or member's condition.
3. Communicate the Decision
   The clinical professionals and supporting specialists communicate decisions to the patient or member and their medical providers.