Utilization Management

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what we do

Comprehensive (prior authorization, pre-payment, or post-payment) utilization management focused on getting the right care that aligns with evidence-based criteria and is in the right setting including with in-network/preferred providers.

how we do it

From working closely with commercial, Medicaid, Medicare, and other insured populations, we understand that individuals are confronted with varying challenges to accessing and obtaining medical care and other support resources. Some are also more prone to isolation and decline due to health problems. Some are also more at risk for negative outcomes, as well as substance abuse and other behavioral health issues.

Our UM offerings are geared toward addressing and reversing those trends by ensuring that providers are directing members to the most appropriate services when they need them – and where they need them.


    Behavioral Health Crisis Services Medical Adult Day Care Validations
    Brain Injury, Medical Adult Day Care, Community Services, PACE, Model Waiver (which include Rare and Expensive Medical children) Programs Minimum Data Set Audits
    Children’s Mental Health Programs Long Term Care/Nursing Facilities
    Chronic Adult/LTAC Hospitals Specialty Pediatric
    Early and Periodic Screening Diagnosis and Treatment Reviews for Applied Behavior Analysis Specialized Reviews (Medical Education and Intervention Team to identify providers with many quality-of-care issues, providers identified as a heavy-opioid prescribers and ones that may be over-utilizing services
    Extended Home Health Reviews


    Why Choose Telligen?

    Our NCQA-aligned, URAC-accredited Qualitrac tool helps us efficiently manage the review process, identify and address utilization patterns, reduce provider burden and streamline data exchange between us and our clients.


        • Average ROI of 5:1 for Medicaid UM
        • Reduced Inpatient Admissions by 10%
        • Average ROI of 7:1 for Commercial UM

    Contact a Health Plan Solutions Expert Today!

    health plan solutions


    caSe management

    value-based reimbursement models

    utilization management

    population health