Utilization Management (UM) Overview
Partners Health Management’s Utilization Management (UM) department ensures equitable access to high-quality, medically necessary services across our service area.
How UM Decisions Are Made
Partners does not offer incentives to UM staff or providers to deny, reduce, limit or discontinue services.
- There are no financial rewards that discourage approval of medically necessary care.
- All UM decisions are based on:
- Medical necessity
- The appropriateness of care
- The service requested
- The existence of coverage
What UM Ensures
Our department uses clinical guidelines to promote quality, evidence-based care that:
- Supports recovery
- Is guided by person-centered practice
- Occurs in the least restrictive and most appropriate setting
- Meets medical necessity criteria
Contact Information
To reach the Utilization Management department:
- Call 1-877-864-1454 (Option 2, then Option 3)
- Email:
- General questions: UMQuestions@PartnersBHM.org
- Specialized funding requests: UMSpecializedFunding@PartnersBHM.org
Providers submit Prior Authorization (PA) Requests/Service Authorization Requests (SAR) through ProAuth to request services for members.
Use this section to:
- Understand PA/SAR request requirements
- Determine when the manual form is needed
- Access submission guidelines
These policies guide decisions about medical necessity under the NC Medicaid Direct plan. They help UM authorize appropriate services for:
- Mental health
- Substance use disorders
- Intellectual/developmental disabilities (I/DD)
- Traumatic brain injuries (TBI)
View Clinical Coverage Policies
For questions, email: UMQuestions@PartnersBHM.org
These policies guide decisions about medical necessity under the Tailored Plan. They help UM authorize appropriate services for:
- Physical health
- Mental health
- Substance use disorders
- Intellectual/developmental disabilities (I/DD)
- Traumatic brain injuries (TBI)
View Clinical Coverage Policies
For questions, email: UMQuestions@PartnersBHM.org
Always refer to these tools to determine whether services require authorization:
These resources outline covered services, service limits, level of care criteria and documentation requirements — including for unmanaged services. They also cover services related to:
- Physical health
- Dental
- Vision
- Pharmacy
View Benefits & Pre-Auth Tools
1915(i) CLS and Innovations CLS Authorization Request Instructions
Step-by-step guidance for submitting SARs for:
- 1915(i) Community Living Supports (CLS)
- Innovations CLS
To supplement the Comprehensive Clinical Assessment (CCA) and Person-Centered Plan (PCP), UM encourages providers to use the following forms to document current symptoms and behaviors for enhanced services. While optional, these forms may be requested by UM:
Providers are required to maintain their own State-Funded Services (SFS) waiting lists and submit updates to Partners at least once per week. These submissions help Partners maintain an accurate, system-wide SFS waitlist.
Note: These forms are not funding requests.
Submit your data using these tools:
- Partners State-Funded Service Request & Waiting List Form
- Direct Form Link (Cognito)
- Provider Weekly SFS Waitlist Submissions Form
For questions, email StateFundsWaitlist@PartnersBHM.org.
Effective July 1, 2024, Durable Medical Equipment (DME) is a physical health benefit under NC Medicaid Tailored Plans. Providers must follow new claim and authorization procedures, not NCTracks.
View the Partners DME Guidance PDF
Some specialty services require prior authorization through a Partners vendor. Providers should use the Prior Authorization Lookup Tool to confirm authorization requirements by service code before submitting a request.
View the Radiology Services Authorization Guidance.
Advanced Imaging
Effective Oct. 1, 2024, non-emergent advanced outpatient imaging services require prior authorization through Evolent. Providers must submit requests through RadMD.
For support, contact Evolent at 800-327-0639.
Musculoskeletal Surgery
Effective April 1, 2026, certain musculoskeletal surgeries require prior authorization through Evolent. Providers must submit requests through RadMD.
For support, contact Evolent at 800-327-0639.
Interventional Pain Management
Effective April 1, 2026, certain interventional pain management procedures require prior authorization through Evolent. Providers must submit requests through RadMD.
For support, contact Evolent at 800-327-0639.
Radiation Oncology
Effective May 1, 2026, radiation oncology procedures require prior authorization through Evolent. Providers must submit requests through Evolent’s CarePro portal.
For support, contact Evolent at 800-327-0639.
Genetic Testing
Effective May 1, 2026, genetic testing services require prior authorization through EviCore. Providers must submit requests through EviCore.
For support, contact EviCore at 1-888-333-8641.