Information about our Utilization Management Program

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All utilization review decisions are based only on appropriateness of care, service, existence of coverage, and setting of the covered service. Please note:

  • We do not use financial incentives in conjunction with our Utilization Management Program.
  • We do not reward doctors who conduct utilization review for issuing denials of coverage or service.
  • We do not offer financial incentives to utilization management decision makers that encourage decisions resulting in underutilization.

To request preauthorization or other utilization management matters, please call the Utilization Management Department at (401) 272-5670 or 1-800-635-2477 (outside of Rhode Island only) during normal business hours: Monday through Friday, 8:00 a.m. to 4:30 p.m. TTY/TDD (Telecommunications Device for the Deaf) services are available by calling 1-888-252-5051 during normal business hours. If you need interpreter services to discuss utilization management matters, please ask one of our representatives about using an interpreter. After hours, if it is a non-urgent matter, you will be directed to leave a brief message with your name and number. Your call will be returned the next business day.

As part of our Utilization Management Program, members have the right to appeal our review decisions. You can find information about our Utilization Management Program in your Member Handbook.

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