The GuidingCare Solution Suite

Utilization Management

Streamline Your Workflows with GuidingCare® Utilization Management Solution

The GuidingCare® Utilization Management module supports the authorization lifecycle – from request and review to status determination to correspondence with members and providers. Helpful clinical guidelines and configurable authorization management workflows help you manage utilization effectively.

Learn More
Utilization management overview

GuidingCare Achieves AA Certification for HEDIS Measures Subset

Ncqa logo 52

GuidingCare Platform & Mobile Clinician App Earn CA Veracode Verified Status

Veracode new

GuidingCare Achieves NCQA Population Health Management Prevalidation

Ncqa logo 1

GuidingCare Platform Achieves HITRUST Certification


Features of Our Utilization Management Solution

Gear arrow
Complete Workflow

Streamlines moving parts in the complex UM process, including Peer Reviews, MD Reviews, and Concurrent Reviews.

Turnaround Time Requirements

Maintain compliance across all lines of business with configurable turnaround time (TAT) by benefit program and authorization type, for review, approval, correspondence and other activities.

Frame (23)
Configurable Workflows

Adjusts to your organization’s specific needs and supports clinically sound workflows for authorizations, reviews and service approvals. Templates automatically pre-populate data to save time and improve accuracy.

Medical vision dental
Clinical Guidelines

Integration between MCG Cite AutoAuth and InterQual Connect support automated decision-making and extensive integration with MCG and InterQual provides users direct access to evidence-based clinical guidelines, so review details are saved against each request, supporting the decision process.

Frame (34)
Integrated Platform

Integrates seamlessly with the GuidingCare solution suite, enabling all stakeholders to track the progress of appeals, along with enrollment, encounter, and care planning information.

Request a Demo

See how your team can benefit from a utilization management solution with a single, comprehensive care record and streamlined authorization and decision workflows.



What is utilization management software?

Utilization management software helps health plans to manage members’ utilization of benefits solution. This type of software streamlines the utilization review process by automating business workflows, enabling seamless access to evidence-based clinical guidelines, and supporting custom configurations that adjust to your organization’s specific needs. Utilization Management software supports the authorization lifecycle from request and review to status determination to correspondence with members and providers with helpful clinical guidelines and configurable authorization management workflows help you manage utilization effectively.

What are the 3 assessments for utilization management?

There are 3 types of assessments in Utilization Management (UM) to review medical necessity: prospective, concurrent, and retrospective. Per CMS, medical necessity is “services or supplies that: are proper and needed for the diagnosis or treatment of a medical condition, are provided for the diagnosis, direct care, and treatment of a medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of the patient or doctor."
-A prospective review looks at whether the services or scheduled procedures are medically necessary prior to admission.
-Concurrent reviews look at whether services or procedures are medically necessary during the time in which a patient/member is in an acute (e.g. a hospital) or post-acute setting (e.g. an outpatient clinic)
-Finally, retrospective reviews determine whether procedures or services are medically necessary after the treatment.

What is the difference between utilization review and utilization management?

Utilization review is the process used to determine whether medical services for patients are being used appropriately (right care, right provider, right setting). Utilization management is the strategy or approach taken based on the utilization review data to improve patient outcomes, manage operations and costs, and ensure optimal utilization for staff and resources.

Rectangle 22 (2)

Care-Payer Integration

HealthRules Payer is even more powerful when combined with GuidingCare®. Our unique Care-Payer Data Exchange solution provides the API-based integration that enables the continuous management of member care and core administrative processes.

Care-Payer provides a range of vital capabilities, including:

  • Standardized core data delivery from HealthRules Payer to GuidingCare
  • Authorization entry workflow improvement, including single-case agreement and referral category enhancement
  • Near-real-time authorization delivery from GuidingCare to HealthRules Payer

Most notably, Care-Payer includes Benefit Predictor integration. This unique feature enables GuidingCare users to quickly and easily answer complex benefit questions prospectively from members and providers.

This Benefit Predictor integration is incorporated into several key workflows, giving Utilization Management staff and care managers unparalleled access to near-real-time benefits information.

Care-Payer Data Exchange delivers significant benefits to your organization, including:

  • Smooth implementation through HealthEdge expertise and standardized processes
  • Synchronized data sets between HealthRules Payer and GuidingCare
  • New levels of operational efficiency in authorization entry and medical management
  • Improved payment integrity
  • Certified data exchange
Learn More

The GuidingCare Solution Suite


GuidingCare is a comprehensive solution for whole-person, patient-centered care, offering easy-to-use, next-generation data integration and workflow management solutions and tools. Our feature-rich solution suite is easy to integrate with existing systems and is highly configurable.

Learn More
GuidingCare Care Management

Our Care Management workflow software provides tools that help you operationalize an evidence-based, person-centered care management strategy for your populations.

GuidingCare Utilization Management

Our Utilization Management module supports the complete authorization lifecycle, including clinical guidelines and authorization management workflows.

GuidingCare Authorization Portal

This intuitive and comprehensive electronic tool eases the preauthorization, appeals and messaging process for your Utilization Management staff and the providers who interface with your plan.

Learn More
GuidingCare Business Intelligence

Our Reporting & Business Intelligence module provides more than 50 standard reports to make ad hoc report-building and analysis simple and actionable.

Learn More
GuidingCare Population Health

Our web-based care coordination application for provider partners incorporates gaps-in-care analytics that enables clinical staff to identify high-risk patients and potential health improvement opportunities.

Learn More
GuidingCare Appeals & Grievances

Our Appeals & Grievances module streamlines and consolidates the entire appeals management process to help you meet regulatory demands for timely resolution and correspondence.

Learn More

Additional Offerings

GuidingCare Medication Therapy Management

Enable pharmacists with a central location in which they can manage member medications and intervene to prevent potentially harmful outcomes.

GuidingCare Pediatric Population Health

Standard and enhanced tracking and reporting to meet federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements in Medicaid.

GuidingSigns® Analytics

A clinical decision support system that transforms data into actionable insights for health care payers and providers.