Utilization Management

Optimize Utilization with HELIOS®

Utilization management is the evaluation of the appropriateness and medical necessity of health care services, procedures, and facilities according to evidence-based criteria or guidelines. HELIOS® was developed to reduce the administrative burden of utilization management. The automation of authorization-related processes, and integration of data into payer’s and provider’s workflows can significantly reduce the manual work involved in following up on authorizations requests, as well as helping eliminate redundant workflows. For utilization management, the HELIOS® platform enables the development of improved policies, high-performing networks, and targeted provider interventions.

One Comprehensive Member View

To promote value-based care within utilization management workflows, payers and providers must be able to easily collaborate at the point of care. Administering the right care in the right setting means that providers need to be able to access relevant data. HELIOS® provides a single unified platform for UM reviewers, including nurses, UM program managers, and medical directors to see a full view of a member. This single unified view includes their clinical care history, case notes, evidenced based approaches and treatments, member’s insurance benefits, and provider networks. The HELIOS® platform also allows providers to directly submit authorization requests.

One Comprehensive Member View

HELIOS® provides an integrated solution that streamlines all major components of the utilization management lifecycle from authorizations to appeals and grievances, while ensuring the determination of any medical service is based on evidence-based guidelines and a complete 360° degree view of the member.

  • Support timely prospective, concurrent, and retrospective reviews
  • Provide transparency between utilization management and care management as members transition across care settings
  • Minimize administrative and operating costs while maximizing productivity and eliminating duplicate data entry and redundant services

Control the Full Utilization Management Lifecycle

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. The platform can be deployed with utilization management criteria frameworks including Change Healthcare's InterQual clinical decision support and MCG's care guidelines. Additionally, clients can configure HELIOS® with the medical policy guidelines developed in-house.

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, 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.
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 vendors.
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 Integrate with EHRs or easily leverage EHR data to trigger relevant workflows
Integrate with EHRs or easily leverage EHR data to trigger relevant workflows
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 Automate approvals and authorizations of medical services and procedures
Automate approvals and authorizations of medical services and procedures
VirtualHealth Utilization Management Capture and process any requests for additional clinical information
Capture and process any requests for additional clinical information
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 Auto-calculate the total cost and the total units
Auto-calculate the total cost and the total units

Timing of Review

Utilization management helps to ensure that providers are maintaining a high quality of care and administering effective treatments while minimizing costs. HELIOS® supports prospective, retrospective, and concurrent reviews. It can be used to improve the working relationship between providers and payers, registered nurses, and care and case managers.

Profitably Deliver A Better Utilization Management Process

Technology and platforms that fit within a collaborative ecosystem of payers, providers, and vendors across the care continuum can improve the process of utilization management. Increased automation of the authorization process will reduce administrative costs, make authorizations more timely, and ensure appropriate care with better outcomes.

A Better Utilization Management Process is Within Reach