Healthcare Utilization Management Program

Partner with Envolve for Utilization Management

Backed by evidence-based guidelines, Envolve Health is committed to ensuring healthcare services are properly utilized by members, reducing wasteful spend for health plans and payers, and ensuring members receive high-quality, medically necessary care. 

Envolve operates an active Utilization Management (UM) program, under the direction of our Chief Medical Director, ensuring the provision of medically necessary covered services.

Our utilization management services are customizable to meet the needs of any plan manager, and is ran by  an expert staff and backed by a robust provider network that grows and changes to meet patients' medical, cultural, language and geographic needs.

A UM Program Focused On Ensuring Members Take the Correct Path To Care

Health plans and payers need a robust solution for utilization management to ensure the most effective health care services, procedures and facilities are utilized to ensure an appropriate path to wellness.

Our UM program  aims to provide services to health plans and payers that are:

  • Covered under the plan benefit
  • Medically necessary
  • Appropriate to the patient's condition
  • Rendered in the appropriate setting
  • Professionally recognized standards of care

Our Utilization Managers thoroughly examine claims data before and after care is rendered, encompassing the functions of:

  • Prior authorization – to eliminate the need for unnecessary services helping reduce denials and ensuring patients are taking the proper path to care
  • Concurrent review – Performed during the course of treatment
  • Retrospective review – Assessing the appropriateness of completed care
  • Benefit determinations using medical necessity criteria and transition of care programs

The goals of our Utilization Management Program are designed to benefit both our clients and their members by:

  • Optimizing patients’ health status, sense of wellbeing, and access to quality care and
  • Helping payers manage cost trends

An Evidence-Based Approach to Utilization Management

Envolve’s utilization management program uses nationally recognized evidence based criteria and has mechanisms in place to ensure services are not arbitrarily denied or reduced based on diagnosis, type of illness or condition.

A UM Services Provider Committed to Health Education and Wellness Promotion

By better educating your population, some healthcare situations can be avoided down the road, helping health plans better manage cost trends.

Envolve offers a comprehensive portfolio of health education and wellness promotion programs including smoking cessation, diabetes management programs, nutrition and weight management, and preventive health screenings that can be offered to members.

Materials used as part of Envolve’s Health Education program are based on clinical practice guidelines promulgated by the leading academic and national clinical organizations such as the American Diabetes Association, American College of Obstetricians and Gynecologists (ACOG), American Academy of Pediatrics (AAP), and the National Heart, Lung and Blood Institute (NHLBI) or as otherwise defined by MCP.

Our health education materials are easy to understand (4th-6th grade reading level or below), with appealing graphic elements, and comply with the American Disabilities Act of 1990 including availability of Braille and audio tapes as indicated. Materials are culturally relevant and produced in English and Spanish and other languages upon request. Education materials are reviewed annually and updated as indicated to maintain accuracy and relevance to the population.

Partner With a Leading UM Company

Envolve Health’s comprehensive utilization management program helps health plans and payers improve coordination of care and put members on the right path to the right care in the right setting.

Our utilization management services are URAC accredited and can be custom-tailored to meet the needs of any payer. Contact Envolve Health today to get started.

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