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How Utilization Management Decisions Are Made
The Dignity Health Medical Foundation- utilization management (UM) program description specifically prohibit the use of incentives for its UM programs or coverage determinations. Bonuses or incentive pay are not used in any way to influence a practitioner's decision to withhold, delay or deny necessary medical services. Any financial incentives used for UM decision makers is not linked or used to encourage decisions that result in underutilization. Practitioners are ensured independence and impartiality in making referral decisions that will not influence: hiring, compensation, termination and/or promotion. [NCQA UM 4.F; 29 CFR 2590.715-2719(b)(2)(ii)(D)]
All coverage determinations (approvals and denials) are reviewed by licensed staff and made based on member eligibility at the time of services, medical necessity, appropriateness of care and services and the availability of existing benefit coverage of the Member's selected health plan and benefit package. To determine medical necessity, specific criteria are applied to the information supplied by the requesting provider. UM Staff is available for additional collaboration with practitioners and members when applicable by calling the customer services number. The reviewer must also evaluate if relevant clinical information has been supplied by the requesting provider and then take into consideration the following factors: individual characteristics such as: age, co-morbidities, complications, progress in treatment, psychosocial situation, and home environment, when applicable. [NCQA UM 3]