The role of the Utilization Management (UM) Department is to ensure consistent delivery of appropriate and quality health care services to our members through Care1st affiliated providers. The UM functions include pre-certification, inpatient concurrent reviews, discharge planning, and retrospective reviews. Health care services are provided through a combination of direct contracts, full and shared risk networks structured to provide a continuum of care.
Care1st Health Plan makes Utilization Management (UM) decisions only on appropriateness of care and service, including existence of coverage. Care1st does not reward practitioners or other individuals for issuing denials of coverage or care. There are no financial incentives that would encourage UM decision makers to make decisions that would result in underutilization of services.

The Criteria
The UM Department uses clinically sound, nationally developed and accepted criteria for making medical necessity decisions. Following is a listing of the clinical criteria used, but is not limited to:

(Care1st Health Plan uses nationally recognized clinical criteria in order to make UM decisions. This criteria is available to you upon request, by contacting (323) 889-6638, extension 6403).