The States review of a Health Plan’s Medical Management program is done to assure that the health plan’s program is designed to make utilization decisions affecting the health care of members in a fair, impartial and consistent manner. The main goal of the Medical Management Program is to oversee and ensure the quality of relevant care while promoting appropriate utilization of medical services and plan resources.

Promoting optimal practice within both medical and behavioral health, while being sensitive to the current structure of the local delivery systems, should be the strategy of a solid Medical Management Program. All components of the program should comply with Federal and State regulations and strive to meet the nationally recognized utilization standards of the National Committee for Quality Assurance (NCQA). The programs should be designed to make utilization decisions affecting the health care of members in a fair, impartial and consistent manner with the main goal of oversight of the delivery of care to ensure quality relevant care while promoting appropriate utilization of medical services and plan resources.

Cherye Morgan LLC and team has experience in leading middle market and national and state health plans in building these capabilities for their members.