Utilization Management Criteria
At Elderplan, we want to ensure you get the right care when and where you need it. Our goal is to ensure that all your health care needs are met in the most effective and efficient way possible. This includes reviewing treatments, hospital stays, services like skilled nursing care, tests, and medical equipment before getting them to ensure they’re necessary and appropriate.
We also monitor your care throughout your treatment to ensure it’s still the right approach and will work with you and your doctors if any changes are needed.
When making decisions about your care, we follow Medicare’s guidelines when available. Medicare sets rules for what’s covered, and we also follow local guidelines in the New York region. If Medicare guidelines aren’t available, we use an evidence-based system called InterQual®, which helps us ensure your care is medically necessary.
If the initial criteria aren’t met, our medical team, including doctors, will review your case to ensure the right decision is made. We won’t deny your care without a doctor’s review.
We believe in being transparent about how we make decisions regarding your care. Below are links to more information about the criteria we use and Medicare guidelines.
- InterQual®: These criteria help guide decisions for different types of services, like hospital stays, home health care, and therapy. You can access it by registering on the One Healthcare site. Please copy and paste this link into your browser and follow the prompts to register: InterQual® Criteria.
We also work with a few partners who follow specific criteria for certain services:
- Care to Care: This partner helps us make decisions about high-tech scans like MRI, PET, and CT scans. Visit their site for more information: Care to Care Criteria.
- Healthplex: This partner helps us manage dental care for our members. If you’re a Medicare member, you can find the criteria here: Healthplex Manual for Medicare.
If you have any questions about our care approval process or need help understanding the criteria, please contact our Pre-Authorization team. You can contact them through Member Services at:
- Phone: 718-921-7979 or Toll-Free at 1-800-353-3765
- Hours: 7 days a week, from 8 AM to 8 PM
- TTY/TDD: 711
