The Utilization Management (UM) department ensures that individuals have equitable access to appropriate care across the Partners catchment area.

Partners does not offer incentives to Utilization Management employees or providers to deny (reduce, terminate or suspend), limit, or discontinue medically necessary services to any member. There are no financial rewards for Utilization Management decision-makers that would discourage approval of services. Decisions made by Partners’ Utilization Management are based only on the appropriateness of care, the service requested, and existence of coverage.

UM ensures quality services through compliance with clinical guidelines. This “compliance” results in individuals receiving services that:

  • Support recovery.
  • Reflect enrollee preferences.
  • Are efficient and cost-effective.
  • Occur in the most appropriate and least restrictive setting.
  • Are consistent with medical necessity criteria.
  • Promote evidence-based practices.

To reach the Utilization Management department, please click on the the following link.

Additional Resources:

  • ProAuth Demonstration Video April 2024
  • Manual Authorization Request Form
    This form is to be used for the following situations:

    • The ProAuth/TruCare system is not available and is not expected to be available for an extended period. For example: 4 hours or more; this information will be communicated via the Partners website.
    • The Provider is an out-of-network and/or non-participating provider who is serving a Partners member who either requires specialty treatment not available in the network, is out of the catchment area when a crisis occurs or lives in another catchment area, but Medicaid is not expected to change. For example, members living in residential situations outside of the Partners catchment area but continue to have Medicaid from one of Partners counties.
    • A service is being requested that is not in the Partners Benefit Plan and is not an available drop-down option for services in the ProAuth/TruCare system. For example, an EPSDT Medicaid request for a service not included in the Partners Medicaid Benefit Plan.
  • Adult/Child/Physical Health Services Review Forms: Utilization Management (UM) recommends that providers use the Adult, Child and Physical Health Services Review Information Forms to provide information on the frequency, intensity and duration of current symptoms and behaviors for members in enhanced services. This is a supplemental form to other clinical documentation such as the Comprehensive Clinical Assessment (CCA) and Person-Centered Plan (PCP). This form will aid in the Utilization Management review. Although these forms are available, this information can be provided in other methods of documentation submitted with the Service Authorization Request (SAR). If this information is not submitted, the Utilization Management Reviewer may request that the provider complete the form.
  • TBI Funding Guidelines
  • TBI Funding Application
  • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
  • ASAM Severity Profile Score Sheet
  • MH/SUD Authorization Calculator

Updated: May 15, 2024