Utilization Management

Prior Notification One of the cornerstones in lowering our client's costs for DME and O&P management concerns finding creative solutions to reduce the hidden costs associated with Utilization Management. One of the primary drivers in the exploding costs of DME and O&P benefit management is the highly expensive cost of utilization management for products and services that should not need such highly skilled workers repeatedly approving the services.



Taking the Utilization Management function out of the front end process greatly reduces your administrative burden and allows ReliaCare to administer your benefit plan the way you designed it – using authorization and adjudication rules that support benefit design and clinical controls. All of these work together to increase patient satisfaction and maintain your standards through thorough back end reporting.


Based on industry standard time and workflow studies ReliaCare is able to show you how much, based on your own data, you are losing in administering the DME benefit. On average a health plan may be maintaining an administrative loss ratio of less than ten percent – and yet they are spending almost 40% to administer their DME benefits. This is not because they don’t know what they are doing – it’s because of the unique nature of the DME and O&P benefit which do not fit neatly into the typical administration of benefits.


To counter this ReliaCare uses state of the art utilization management protocols based on the client’s clinical criteria and benefit design. The bottom line is greatly reduced costs, increased member satisfaction and, ultimately, better patient outcomes.



  • Credentialing & Contracting
  • Price Setting
  • Benchmarking & Reporting
  • Access Guarantees
  • Follow payer and regulatory guidelines
  • Follow benefit design
  • Physician Outreach
  • Patient/Family Coordination
  • Delivery Confirmation
  • Regulatory guidelines followed
  • Electronic submission increased
  • Reporting to support benchmarking
  • All languages supported
  • Multi-tiered Operational Reporting
  • Extensive Data Aggregation