Utilization management best practices and tips

We’re offering some guidance around best practices and tips for utilization management (UM) requests and transactions so that CarePartners of Connecticut and our provider partners can work together as efficiently as possible for a positive shared experience. 

These tips highlight just a few common issues and opportunities for improved collaboration, based on feedback from our provider community and our UM staff who work to help facilitate essential functions so that our providers can continue to deliver best-in-class care to our member population.  

Benefits and eligibility

When looking to confirm a member’s benefits and eligibility prior to initiating care or referring them for a service, the best place to start is our secure provider portal. This reference guide offers more guidance on how to use the portal to verify benefits and eligibility. 

We encourage you to use the electronic self-service capabilities offered via the provider portal whenever possible for its ease of use and quick turnaround times. When looking up your patient in the provider portal, for many members you’ll be directed to MHK, which is the medical management tool accessed from within the provider portal. MHK allows you to perform a number of transactions efficiently in one place, such as submitting referrals and authorizations, finding the status of a claim, providing inpatient notification, and more. It’s the most direct way to submit requests, providing real-time determinations and allowing you to attach clinical documentation and notes. 

Alternatively, if the member has an Advantage Plus Network – Connecticut (APN-CT) primary care provider (Hartford Healthcare Medical Group and ProHealth Physicians), you’ll be directed to the Optum Pro portal.

Updating an authorization 

If you initiated a request for prior authorization but need to make any changes to the information (e.g., the number of visits listed, diagnosis or procedure codes, the date range), the authorization should be submitted again as a new request. While we encourage you to use the applicable provider portal to do this, you may also choose to submit the request via fax. 

• As a reminder, if one of your CarePartners of Connecticut patients has an APN-CT PCP, you should request authorization directly with APN-CT. You can submit the request to APN-CT in one of the following ways:
• Online: via the Optum Pro portal at optumproportal.com (Have questions? Select Contact Us in the portal to submit your question or issue.) 
  Phone: 1-888-556-7048, 8 a.m.–6 p.m. ET, Monday–Friday (only if online unavailable)

After submitting a request either electronically or by fax, please allow CarePartners of Connecticut a reasonable amount of time to review the request and respond. Submitting multiple requests unnecessarily may delay processing, as our UM team will need to review each request separately. 

Include all necessary information

Please remember to include all pertinent information when submitting an authorization or other UM request. This includes any appropriate clinical documentation, the provider’s NPI or TIN, or any other identifying information necessary to convey a complete picture of the request or encounter so that we can process it without the need for provider resubmission. 

Provider Service Center 

For assistance with any functions you’re unable to perform using our electronic self-service tools, we encourage you to contact the Provider Service Center at 888.341.1508. We do not recommend calling other CarePartners of Connecticut departments such as UM directly for support, as the Provider Service Center is staffed and trained more appropriately to handle such inquiries.