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PROCESS |
Utilization Management Process
(Policy and Procedure/Revised January
2011.)
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CRITERIA |
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As a provider of healthcare, if you request a referral or service for a UPHP member, it must be medically necessary. If there is a question about medical necessity, UPHP must
utilize objective, measurable criteria that are based on reasonable medical evidence in a fair, impartial and consistent manner. |
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Clinical decisions are made based on appropriateness of care as it relates to intensity of service and severity of illness. UPHP does not reward those making clinical
decisions on behalf of UPHP for issuing denials or encouraging under utilization patterns. Neither does UPHP endorse, from any source, any type of incentive or monetary reward for influencing utilization
or referral patterns. |
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If your request is denied due to lack of medical necessity you may request a copy of the criteria which was used by UPHP in making that determination and/or you may speak to
the MD reviewer responsible for the determination. You may make your request in writing or by telephone. We will be happy to give you the criteria verbally over the telephone or if you prefer, we can
mail or fax you a copy of that criteria. |
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If you have any questions in regard to availability of utilization criteria please call UPHP @ 1-800-835-2556 and follow the prompts to Customer Service. If you would
like to speak to the MD reviewer, please call UPHP @ 1-800-835-2556 and follow the prompts to Clinical Services. A time will be arranged for a telephone conference. |
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Out-of-Plan Services |
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Inpatient Admissions |
- 2011 InterQual® Level of Care Adult and Pediatric Criteria
(including inpatient and observation status)—Available on request.
[InterQual® is a registered trademark of McKesson Health Solutions, L.L.C.]
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Michigan Department of Community Health (MDCH) Criteria
The following MDCH criteria are available at
www.michigan.gov/mdch:
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- In-Plan and Out-of-Plan Inpatient Readmissions Within 15 Days
- Durable Medical Equipment
- Skilled Nursing Facility/Swing-Bed Admissions
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Medically Necessary Weight-Reduction Services
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Medically Necessary Reconstructive Surgery
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PROVIDER APPEALS
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Provider Post Service Appeals
(Policy and Procedure /Revised
November 2008.)
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