Surgical Procedures Solution
Bring smart surgical care to the right place
As part of an overall medical benefits management approach, our Surgical Procedures Solution helps your health plan improve outcomes and manage the cost of care. Our solution uses evidence-based guidelines and utilization review to evaluate services including gastrointestinal and ear, nose, and throat procedures for clinical appropriateness and site of care. We also partner with providers to support informed care decisions and help improve outcomes.
Lines of business
- Commercial
- Medicare
- Medicaid
- Federal employee
What if the entire surgical care experience worked better?
Along the surgical procedures care journey, there are opportunities to remove the barriers between your members and important surgical care, make their experience easier and more modern, and help create meaningful savings for your health plan. Our solution helps make those opportunities possible.
Make surgical care more accessible and sustainable
Our solution helps health plans make better use of outpatient surgical settings, reducing reliance on hospitals and other high-cost settings when appropriate.
Support high-quality care and lower costs
We help drive value and support high-quality, patient-centered care by evaluating common gastrointestinal and ear, nose, and throat surgical procedures for clinical appropriateness.
Create a seamless, connected provider experience
Our automated platform and provider engagement resources help make it easier for your providers to adopt our solution.
What’s included in our Surgical Procedures Solution
Our solution brings together clinical review, site-of-care support, provider engagement, and insights to help your health plan manage surgical care more effectively.
Clinical appropriateness review
Clinical setting optimization
Practice engagement resources
Advanced analytics and reporting
How surgical procedures management and utilization review work
Request
Your providers submit requests to us online or by phone.
Review
Our automated platform reviews requests in real time against applicable clinical criteria.
Determine
Requests that meet clinical criteria can be approved immediately. When additional review is needed, our clinical reviewers, including board-certified surgeons and nurses, are available to consult with your providers about requests that don’t meet our clinical criteria or the health plan’s medical policy.
Redirect
When clinically appropriate, we can redirect surgical procedures to high-value sites of care.
Synchronize
We share request data with your systems for claims, care management, or reporting purposes, as applicable.
Ask us about our Surgical Procedures Solution
Connect with us to explore the potential impact of our Surgical Procedures Solution for your health plan.
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Frequently asked questions about surgical procedures
Are you a health plan member?
If you’re a health plan member and have a question about your health plan, please call the Member Services number on the back of your member ID card.
Provider inquiries: For questions about a request or the Provider Portal: Call 800-252-2021 or contact our support team .
Business hours: 8 a.m. to 5 p.m. CT.