Utilization Management

Partner with Envolve for Utilization Management

Envolve operates an active Utilization Management (UM) program, under the direction of our Chief Medical Director, ensuring the provision of medically necessary covered services. We work to customize, operate and maintain an effective Utilization Management Program through an expert staff and a robust provider network that grows and changes to meet patients' medical, cultural, language and geographic needs.

Envolve's Utilization Management Program aims to provide services that are:

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

Our Utilization Management Program encompasses the functions of:

  • Prior authorization
  • Concurrent review
  • Retrospective review
  • Benefit determinations using medical necessity criteria and transition of care programs

The goals of our Utilization Management Program are to optimize patients’ health status, sense of wellbeing, productivity, and access to quality healthcare, while at the same time actively managing cost trends. 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.

Health Education & Wellness Promotion

Envolve offers a comprehensive portfolio of health education and wellness promotion programs including smoking cessation, diabetes management, nutrition and weight management, and preventive health screenings.

Materials used as part of Envolve’s Health Education program are based on clinical practice guidelines (CPGs) promulgated by the leading academic and national clinical organizations such as the American Diabetes Association (ADA), 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.

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