Important Information about UniCareís Utilization Management Process
Our utilization management (UM) decisions are based on the appropriateness of care and service needed, as well as the memberís plan coverage.
Notice regarding financial incentives
- We do not reward providers or other individuals for issuing denials of coverage, service or care.
- We do not make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits.
- We do not offer financial incentives for UM decision makers to encourage decisions resulting in under-utilization.
View UniCareís Medical Policies, Clinical UM Guidelines & Clinical Criteria, clinical UM guidelines and clinical criteria.
You can also request a copy of our UM criteria for a specific condition from our Medical Management department.
Providers may discuss a UM denial decision with a physician reviewer by calling UniCare at
Responding to your inquiries
We work with providers to answer questions about the utilization management process and the authorization of care. Hereís how the process works:
- Call us at 800-442-9300 Monday through Thursday from 8:30 a.m. to 6:00 p.m. and Fridays from 8:30 a.m. to 5:00 p.m. (Eastern Time).
- If you call after normal business hours, you can leave a private message with your contact information. Our staff will return your call on the next business day. Calls received after midnight will be returned the same business day.
- Our associates will contact you about your UM inquiries during business hours, unless otherwise agreed upon.
For language assistance, members can call the Member Services phone number on the back of their ID card and a representative will assist them.
Our Utilization Management associates identify themselves to all callers by first name, title and our company name when initiating or
returning calls. They can inform you about specific utilization management requirements, operational review procedures, and discuss
utilization management decisions with you.