Utilization Management decision making is
based solely on appropriateness of care and
service and existence of coverage. Your group
does not specifically reward practitioners or
other individuals for issuing denials of coverage
or service care. Financial incentives for
utilization management decision makers do not
encourage decisions that result in underutilization.
If you want to obtain a copy of the decision
making criteria utilized by your group for service
decisions, this information is made available to
the public upon request by contacting our
Member Services Department at (888) 445-0062.
The group is only required to disclose the criteria
or guidelines for specific procedures or
conditions requested.
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