Clinical Resources

Utilization Management (Prior Authorizations & Predeterminations)

Review information related to Utilization Management (Prior Authorizations & Predeterminations) - Content now available under Claims and Eligibility menu


Learn more about Prior Authorizations and the Radiology Quality Initiative (RQI) Program through Carelon Medical Benefits Management.

Behavioral Health Care Management Program

Learn more about the Behavioral Health Care Management Program.

eviCore Prior Authorization Program

Learn more about the eviCore Prior Authorization program.

Pre-cert/Pre-auth Router (for out-of-area members)

Have the three character prefix ready to find medical policy, pre-certification and pre-authorization information (for out-of-area members).


Other Clinical Resources Programs

Clinical Practice Guidelines

Learn more about clinical practice guidelines.

Preventive Care Guidelines/Patient Wellness Guidelines

Learn more about Preventive Care Guidelines/Patient Wellness Guidelines

Quality Improvement

Our Quality Improvement Department strives to provide products and services of the highest quality and value with a direct focus on meeting the needs of the customer. The process for delivery of care and services is constantly changing offering ongoing opportunities for improvement.

We support our health care provider’s efforts to provide quality services and products and believe that through monitoring and evaluation, we can work together to benefit both members and health care providers. This resource applies to our commercial and retail products and was created as a reference for clinical quality improvement. To assist our providers, we also provide Quality Improvement HEDIS® Tip Sheets and resources for delivering quality care.

Special Beginnings — A Maternity Program

Learn more about our Special Beginnings maternity program — a healthy start for mothers and babies.

Telemedicine and Telehealth Services

Review information on providing Telemedicine and Telehealth Services to our members including what’s covered, submitting claims and telehealth vendors.