In accordance with the benefits available under the member?s health plan and our definition of medical necessity, it is our policy that all utilization review decisions are based on the appropriateness of health care services and supplies. Only physicians who conduct utilization reviews may make denials of coverage of health care services and supplies based on lack of medical necessity.

The nurses, medical directors, other professional providers, and independent medical consultants who perform utilization review services for us are not compensated or given incentives based on their coverage decisions. Medical directors and nurses are salaried employees, and contracted external physicians and other professional consultants are compensated on a per-case reviewed basis, regardless of the coverage determination. We do not reward or provide financial incentives to individuals performing utilization review services for issuing denials of coverage. There are no financial incentives for such individuals that would encourage utilization review decisions that result in denials or underutilization.

Providers are encouraged to enter all routine requests for authorization through the NaviNet^® web portal. If there are any requests that require immediate review or if NaviNet is not available, please contact the Utilization Review department at 1-800-275-2583 for providers in Pennsylvania and Delaware or at 1-888-YOUR-AH1 (1-888-968-7241) for providers in New Jersey. Facilities can also call the Utilization Review department for ambulance and discharge planning needs.

More information about our utilization review policy and availability, as well as other provider-related information, can be found on the Resources for Patient Management web page.

NaviNet^® is a registered trademark of NaviNet, Inc.