Utilization Management

Mutual of Omaha’s Utilization Management program is designed to help you evaluate the medical necessity of your recommended treatment and identify whether or not a procedure can be certified under the terms of your plan.

Precertification Review

If your health plan requires precertification, you will need to receive approval from Mutual of Omaha before you obtain certain treatments, services and/or supplies in order for you to qualify for full medical benefits.

During the precertification review process, our staff can help you or your physician answer important questions, such as:

• Is the treatment appropriate for the diagnosed condition or symptom?
• Is the proposed level of care necessary or could services be safely and effectively provided at a lower, less costly level of care?
• Is there a less risky, medically appropriate treatment alternative?
• Are there any extra expenses included as part of the treatment?
• Is the proposed treatment or service a covered benefit under your plan?
• Are the proposed health care providers considered in-network providers under your plan?

Of course, any decision regarding treatment is left up to you and your physician. Precertification review can help you make a more informed decision before undergoing any recommended treatments.

How Precertification Review Works  

• If your physician recommends a treatment or service that requires precertification, remind him or her that you will need to obtain precertification.
• You or your physician should call the precertification phone number listed on your ID card 7 days prior to a scheduled treatment, but at least one business day prior to the treatment. If you are admitted to the hospital on an emergency basis, call the precertification phone number by the second business day following admission.
• When you call, the precertification staff will review the diagnosis, recommended treatment and proposed level of care. They will compare proposed procedures to those of medically accepted guidelines for treating your condition.
• If necessary, the review staff will contact your physician for additional medical information.
• You, your physician and/or the hospital will be notified in writing of the review decision.

If You Have Questions

Please refer to your Benefits Document for your plan’s specific precertification requirements or call the toll-free Customer Service phone number on your ID card.