Utilization Management

HELIOS provides tools to streamline all facets of utilization management and ensure the determination of a medically appropriate service.

  • Support timely prospective, concurrent, and retrospective reviews
  • Reduce the number of appeals and grievances by certifying members receive appropriate care
  • Provide transparency between utilization management and care management as members transition across care settings
  • Minimize administrative and operating costs while maximizing productivity and eliminating waste

Control the Full Utilization Management Lifecycle

A seamless authorization workflow provides care teams with powerful tools to make timely and accurate utilization management decisions.

HELIOS can be used on a standalone basis to provide the complete workflow for both episodic and chronic service authorization requests or integrate with a third-party system.

VirtualHealth Utilization Management Authorization Requests
Authorization Requests
Authorizations are fully integrated in the HELIOS platform, whether sourced from the provider, the care manager requesting services, or a third-party system.
VirtualHealth Utilization Management Auto-Approval Rules
Auto-Approval Rules
The embedded rules engine and an extensive library of configurable clinical rules enables auto-approvals and auto-pends, distinguishes between authorization types, and supports rule hierarchies.
VirtualHealth Utilization Management Medical Review Workflows
Medical Review Workflows
Pending authorizations are automatically routed with all necessary information available to the reviewers. HELIOS supports prospective, concurrent, and retrospective reviews.
VirtualHealth Utilization Management Determination
Determination
Reviewers can solicit additional information and refer to clinical content and industry guidelines that can be configured to an organization’s specific needs. Level of care guidelines can be automated directly or via integration with industry-leading clinical content products.
VirtualHealth Utilization Management Correspondence
Correspondence
HELIOS provides authorization-specific letter templates that can be automatically or manually generated and are automatically attached to the corresponding authorization.
VirtualHealth Utilization Management Appeals and Grievances
Appeals and Grievances
Appeals are tied to the utilization management workflow and grievances and critical incidents can be recorded as part of integrated case management. Both are subject to reporting and configurable workflows for tracking, management, and resolution.

The workflows can be tailored per group or product line to enable providers and care team members to electronically submit authorization requests using a customizable form that can:

VirtualHealth Utilization Management Incorporate client-defined or third-party evidence-based clinical guidelines
Incorporate client-defined or third-party evidence-based clinical guidelines
VirtualHealth Utilization Management Support and track clinical review
Support and track clinical review
VirtualHealth Utilization Management Monitor the timeliness of determinations in accordance with regulatory guidelines
Monitor the timeliness of determinations in accordance with regulatory guidelines
VirtualHealth Utilization Management Route requests for medical review to appropriate parties at the right time
Route requests for medical review to appropriate parties at the right time
VirtualHealth Utilization Management Record the final organizational determination
Record the final organizational determination
VirtualHealth Utilization Management Communicate the determination to the provider and member by auto-populating configurable correspondence templates
Communicate the determination to the provider and member by auto-populating configurable correspondence templates
VirtualHealth Utilization Management Capture and process any requests for additional clinical information
Capture and process any requests for additional clinical information
VirtualHealth Utilization Management Auto-calculate the total cost and the total units
Auto-calculate the total cost and the total units
VirtualHealth Utilization Management Conduct auto-approvals or auto-pends
Conduct auto-approvals or auto-pends