PROCESS

Utilization Management Process
(Policy and Procedure/Revised January 2007.)

CRITERIA

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.

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.

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.

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.