Info Sheets (Digital)

Utilization Management

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HMS has been advancing healthcare for decades with highly regarded payment accuracy, cost avoidance and population health management solutions. To help state Medicaid programs fight cost while managing and improving population health, we've designed a package of solutions that bring our expertise and experience to ensure payment accuracy, manage care and engage members. Together, these solutions create HMS' Utilization Management services. Stop Juggling and Act with HMS' Utilization Management Services HMS' Utilization Management is a combination of population health management and payment accuracy services that address the top priorities of Medicaid programs. Our industry-proven solutions deliver key benefits including: y Improved payment accuracy and better cost management with accurate claim reviews, utilization management and prior authorization from HMS' Clinical Care Reviews. y Seamlessly-managed member care plans with individual assessments, specific interventions and interdisciplinary care team involvement through HMS' Essette Care Management. y Enhanced member retention and associated revenue, lowered costs due to health risk and improved quality measures, such as STARS and QRS quality scores, through member health engagement powered by HMS' Eliza. Payment and Care Accuracy Reviews Avoid Cost and Ensure Appropriate Care HMS' extensive range of payment accuracy and clinical care reviews set the standard for the industry. Reviews can be made pre- or post-payment. As the name implies, a pre-payment review avoids the cost of inappropriate claims by making a claim determination before payment has been made. Post-payment review occurs when a reviewer makes a claim determination after the claim has been paid. State Medicaid programs juggle several priorities, all of them challenging. With finite funding, they're accountable for ensuring resources are used as effectively as possible. Yet, ensuring their members receive appropriate care in the right place of service and at the right cost requires deeper resources and capabilities than some programs can muster. They need the expertise, efficiency and effectiveness provided by HMS' Utilization Management services. A package of solutions to ensure payment accuracy, manage care and engage members. Ensuring the Right Care at the Right Time and at the Right Cost Payment accuracy, care management and member engagement to protect Medicaid programs H M S U T I L I Z A T I O N M A N A G E M E N T

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