Utilization Management
Applying evidence-based clinical review to support appropriate care and responsible plan administration
Protecting the Plan.
Supporting Members.
Ensuring Appropriate Care.
Innovative Care Management’s Utilization Management program helps plans protect benefit assets while ensuring members receive clinically appropriate, high-quality care. Our approach helps plans fulfill their fiduciary responsibility, ensuring appropriate plan administration and thoughtful use of plan assets, while keeping patient-centered, evidence-based decision-making at the forefront. These two are not at odds.
Clinically Focused. Accredited. Independent.
Through ICM’s URAC Health Utilization Management-accredited program, experienced nurses and physicians apply nationally recognized clinical guidelines to support utilization management decisions.
As an independent organization, ICM provides utilization management services that are transparent, defensible, and designed to support the plan’s fiduciary responsibilities.
Utilization Management Services Include
Medical necessity review across pre-service, concurrent, & post-service care
Inpatient and outpatient utilization review
Level-of-care and length-of-stay management
Early identification of high-cost and high-risk episodes
Collaboration with providers to support appropriate care delivery
Physician and specialty reviews
Seamless referral to care management, clinical navigation, or transitions of care when additional support is needed
Medical necessity review across pre-service, concurrent, & post-service care
Inpatient and outpatient utilization review
Level-of-care and length-of-stay management
Early identification of high-cost and high-risk episodes
Collaboration with providers to support appropriate care delivery
Physician and specialty reviews
Seamless referral to care management, clinical navigation, or transitions of care when additional support is needed
This integrated model allows utilization management to function as a clinical intervention point, not a standalone administrative process.
Member-Focused by Design
While utilization management plays a critical role in cost containment, ICM recognizes that members experience utilization decisions personally. Clear communication, timely determinations, and respectful collaboration with providers help reduce confusion and frustration for members—supporting adherence to care plans and better outcomes.
When appropriate, utilization management findings are seamlessly connected to other clinical programs, such as case management or transitions of care, ensuring members receive the support they need beyond the authorization decision.
Protecting the Plan Through Better Care
Effective utilization management is not about denying care—it is about ensuring care is appropriate, necessary, and delivered efficiently. When care is clinically sound and well-coordinated, plans benefit from lower unnecessary spend, and members benefit from safer, more effective care.
ICM Utilization Management Services in Action
Case Study1
How We Reduced Inpatient Length of Stay Through Early Discharge Planning
During concurrent utilization review for an inpatient admission, an ICM nurse identified opportunities to support earlier discharge planning. By collaborating directly with the hospital care team, the nurse helped align discharge needs, post-acute services, and clinical readiness sooner in the stay.
As a result, the member was safely discharged several days earlier than initially projected, avoiding unnecessary inpatient days while maintaining appropriate follow-up care. The intervention reduced hospital costs for the plan and supported a smoother transition home for the member.
Case Study2
How We Helped Identify the Most Appropriate Care Path for Hip Replacement Surgery
During pre-service utilization review for a planned hip replacement, an ICM nurse identified that conservative treatment options had not yet been fully explored. The nurse worked with the provider to review clinical guidelines and discuss appropriate next steps.
The member was directed to outpatient physical therapy prior to surgery and responded well to conservative treatment, with improved function and symptom control. As a result, surgery was avoided, eliminating an unnecessary procedure and associated costs while supporting a positive outcome for the member.
Additional Services to Consider
ICM’s Utilization Management solution is particularly effective at controlling costs while supporting member well-being when combined with the following services.
Member Engagement Services
Help members use their coverage effectively with member navigation, integration support, external vendor outreach and single point of contact concierge services.
Case Management Services
Provide guidance during experience or complex claims with case management, chronic condition management and maternity management.
Chiropractic Utilization Management
Provides prospective and retrospective medical necessity review, ideal for plans with generous coverage for chiropractic services.
Frequently Asked Questions
How is success measured in utilization management?
How does ICM decide which services require preauthorization?
How does ICM balance cost control with the member experience?
How does ICM work with providers?
What can members expect from ICM’s Utilization Management services?
Members can expect clinically guided, respectful reviews focused on ensuring care is medically necessary and provided at the appropriate level. ICM communicates decisions clearly and in a timely manner.