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District of Columbia

Medical management model

Utilization Management

Our Utilization Management (UM) program uses an integrated medical management model based on the physical, behavioral, and social needs of enrollees. The UM program, in collaboration with other departments such as Case Management and Condition Care, facilitates the delivery of the most appropriate medically necessary care to enrollees in the most cost-effective, least restrictive setting.

By collecting individualized data from enrollment information, historical claims data, and ongoing concurrent review, we develop a predictive model that stratifies enrollees into levels of care that determines the level of intervention. Stratification is refined and targeted to those conditions and episodes of care that are most impactful. The care plans developed based on this information are specific to the enrollee’s needs. The enrollee’s provider(s) are also engaged in the development and execution of the plan so the care is integrated across physical, behavioral, and social spectrums.

Case management model

Our enrollee-centric case management model integrates behavioral, physical, and social factors into each individual enrollee’s plan of care. Our model features the early identification of needs, continuous assessment of health, and an enrollee home approach that promotes collaboration among enrollees, family, service coordinators, providers, and community resources.

This approach to case management was specifically designed to meet the needs of Medicaid recipients, including those with disabilities and special healthcare needs.

To learn more about our Utilization Management program or our case management model, please refer to your provider manual or contact Provider Services .

Provider tools & resources

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We look forward to working with you to provide quality service for our enrollees.