U
Definition
The evaluation of the medical necessity, appropriateness, and efficiency of the use of transportation services. It is the process Brokers use to decide if a member gets a sedan, a wheelchair van, or a bus pass.
Overview
Why it Matters
UM is the primary cost-control mechanism. It prevents "waste" by ensuring patients don't use expensive wheelchair vans when they can walk to a bus stop.
How it Works
A nurse or reviewer analyzes the member's diagnosis and mobility form. If the member requests a mode of transport higher than their condition warrants, UM denies it or downgrades the mode.
Code Comparison
Comparison: UM vs. Claims Processing
UM happens before the trip (Authorization).
Claims happens after the trip (Payment).
Common Questions
- Static Data: UM relying on a mobility form from 2 years ago, denying a wheelchair van for a patient who recently had a stroke.
- Friction: High denial rates lead to member complaints and appeals, which increase administrative overhead.
- Submit a "Physician Certification Statement" (PCS) with detailed clinical notes to support the need for higher levels of service, helping UM make the right decision faster.
Sources
Institute of Medicine - Utilization Management