Utilization Management

In keeping with DFS guidance, MetroPlusHealth’s UM protocols will resume on June 22, 2020.

On June 22, 2020, MetroPlusHealth will resume issuing Prior Approvals and performing concurrent review. A grace period will be provided for hospital services that have been scheduled during the week of June 22, 2020 since hospitals were unable to obtain Prior Approval. As a result, MetroPlusHealth will not deny claims for hospital services provided on or after June 18th through July 6th solely due to lack of Prior Approval.

MetroPlusHealth will resume retrospective reviews for medical necessity beginning June 22, 2020.  MetroPlusHealth shall follow DFS guidance with regard to retrospective reviews.

For information regarding MetroPlusHealth’s Utilization Management guidelines, please see here.

last updated: July 17, 2022

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