Utilization Management Program of the Naval Hospital Guam

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The Utilization Management Program of the Naval Hospital Guam facility is one which is designed to ensure that high quality, cost efficient health care is delivered to all members of the community. The Utilization Management Division is responsible for implementing a Utilization Management Plan which will monitor the appropriate usage of the health care facilities, services and its resources…

Introduction


Specialist Referrals- The Primary Care Physician (PCP) may request a consultation from a participating specialist physician at any time.The PCP determines the number of visits authorized.Specialists may include - Gynecologist, Radiation Oncologists, Ophthalmologists, Pediatric Ophthalmologists, Retinologists and Allergists etc.
Emergency Room Services -An emergency medical condition is defined as a condition that manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following:
Out-of-Plan Referrals- All out-of-Plan referrals require Plan prior authorization at Guam. These requests are reviewed on an individual basis. Determinations are made based on the patient's medical needs and the availability of services to meet these needs within the provider.
Tertiary Care Services- All referrals to plan tertiary care centers are reviewed on an individual basis.The member's medical needs and the availability of requested services within the non ...
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