Acentra provides medical case management and utilization review for the Plan. Utilization review is a process to make sure that the care participants receive is medically necessary, delivered in the most appropriate location, and follows generally accepted medical standards. Utilization review provides clinical review and certification of the medical necessity of care. Certification of medical necessity does not guarantee that services are covered. Benefits are subject to the patient's eligibility at the time charges are actually incurred, and to all other terms, conditions and exclusions of the Plan.
This article provides an overview of the medical case management and utilization review process for the health insurance plan.