The Utilization Management Department
The function of the Utilization Management (UM) Department is to ensure consistent delivery of appropriate and quality health care services to our members through Care1st Health Plan Arizona, Inc. network of providers. The UM primary roles include prior authorization, case management, inpatient concurrent reviews, discharge planning, and retrospective reviews. Health care services are provided through contracted health care providers, to provide a wide range of care.

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

• AHCCCS Guidelines
• Milliman Care Guidelines
• Care1st Guidelines
• American College of Obstetric and Gynecology
• The American Academy of Pediatrics
• The United States Preventative Services Task Force Standards
• The Department of Health and Human Services Health Care Guidelines
• CMS Guidelines


The criteria will be made available to the members, providers, and the public upon request.