Utilization Management

Purpose and Function

The Utilization Management Department works closely with but independent of both the Case Management & Clinical Documentation Departments. In contrast to our affiliates or other facilities where these functions/departments may be combined, it is a split model at Flint McLaren.


Utilization Review (UR), also known as Utilization Management (UM), facilitates appropriate utilization of resources in the acute care setting enhancing both patient and organizational outcomes through:

  • Admission status review
  • Compliance with hospital admission screening criteria, third party payer guidelines and state regulations
  • Review of clinical documentation in the medical record to support medical necessity

This information is used to:

  • Determine the appropriate admission status (inpatient, observation, and extended recovery) on a case by case basis
  • Prevent the financial burden of unnecessary copays to the patient
  • Support compliant billing practices
  • Prevent payment denials to both the hospital and the physician.

Medicare/Medicaid HMO CMS Guidelines

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Third Party Payer Guidelines

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Appeals & Denials

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