Utilization Management

Onicol's Utilization Management (UM) is overseen by the UM Committee which is responsible for insuring the proper application of the MAB's Protocols and Pathways in the UM process. The UM Committee is also responsible for making recommendations and reviews of particular Protocols and Pathways based on requested services made by Providers. The UM is a living and breathing process that requires continual adherence, review and possible modification of Protocols and Pathways based on a variety of factors. Changes are made to Protocols and Pathways through all our oversight mechanisms including the Utilization Management (UM) process, Pharmacy and Therapeutics (P&T) Committee and MAB. As these changes are made our Medical and Pharmacy Management Systems will be updated simultaneously to reflect those changes. Below are the steps we use to ensure fast and accurate authorization:

  • All authorizations that are pended will be reviewed by Care Managers (nurses trained in each subspecialty) or by the Medical Director within a specified time frame
  • All authorizations that cannot be approved by the Care Managers will immediately be forwarded to a Medical Director or the full UM Committee for review
  • Nurse CM's and Medical Directors work directly with the office staff and providers to resolve all medical necessity reviews