Wellness Works!

Utilization Management

  • Pre-certification of Medical Services
  • Concurrent Review
  • Discharge Planning
  • Retrospective Review
  • Medical Necessity Reviews
  • Claim Negotiation
  • Bill Auditing Services

The Pre-Certification Program ensures that only patients who require acute care hospitalizations are certified for the diagnosis. Our highly-specialized team of doctors and nurses view the best patient outcomes as their goal, while ensuring opportunities for cost savings are maximized. Cases are continually monitored for quality and appropriateness of care by benchmarking against nationally accepted criteria to assure:

  • Appropriate length of stay
  • Transfer to lower levels of care, when appropriate
  • Alternative more cost effective settings of care
  • Anticipatory proactive and intensive discharge planning initiated at time of admission
  • Avoidance of unnecessary /over-utilization of services
  • Maximum quality care while minimizing costs to the payer


WellChoice, Inc. investigates questionable and complex claims involving reasonable and customary fees, over-utilization, and medical necessity. In addition to our nursing staff we utilize the expertise of board certified medical and surgical specialists, when appropriate.