Utilization Management

We are committed to maintaining the quality and appropriateness of health care services provided to our members. The Utilization Management department performs all utilization management (UM) activities including prior authorization, concurrent review, discharge planning and other activities. TrueCare makes its UM criteria available in writing by mail, fax, phone or email and on this webpage.

•  Phone: 1-833-230-2174
• Fax: 1-937-396-3677
• Mail: TrueCare
  Attn: Utilization Management Dept.
  P.O. Box 1307
  Dayton OH 45401-1307

On an annual basis, TrueCare completes an assessment of satisfaction with the UM process and identifies any areas for improvement opportunities.

Prior Authorization

TrueCare understands that you may have questions about prior authorization. Please visit our Prior Authorization webpage.

Medical Necessity Criteria

TrueCare utilizes nationally recognized criteria to determine medical necessity and appropriateness of inpatient hospital, rehabilitation and skilled nursing facility admissions. These criteria are designed to assist health care partners in identifying the most efficient quality care practices in use today. They are not intended to serve as a set of rules or as a replacement for a physician’s medical judgment about individual patients. TrueCare defaults to all applicable state and federal guidelines regarding criteria for authorization of covered services.

We also have policies developed to supplement nationally recognized criteria. If a patient’s clinical information does not meet the criteria, the case is forwarded to a TrueCare Medical Director for further review and determination. Physician reviewers from TrueCare are available to discuss individual cases with attending physicians upon request.

Utilization review determinations are based only on appropriateness of care and service and existence of coverage. TrueCare does not reward health care partners or our own staff for denying coverage or services. There are no financial incentives for our staff members that encourage them to make decisions that result in underutilization.

Our members’ health is always our number one priority. Upon request, TrueCare will provide the clinical rationale or criteria used in making medical determinations. You may request the information by calling or faxing the TrueCare Utilization Management department.

If you would like to discuss an adverse decision with physician reviewer, please call the Utilization Management department at 1-888-880-4889 within five business days of the determination.

Access to Staff

Providers may call 1-888-880-4889 to contact Utilization Management staff with any UM questions.

In the best interest of our members and to promote their positive health care outcomes, TrueCare supports and encourages continuity of care and coordination of care between medical health care partners as well as between behavioral health care partners.