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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 under-utilization.
Providers are encouraged to enter all routine requests for authorization
through the NaviNet® web portal. Providers can call
1-800-ASK-BLUE if there are any requests that require immediate review,
involve members with coverage through the Federal Employee Program, or if
NaviNet is not available. Facilities can also call 1-800-ASK-BLUE for
ambulance and discharge planning needs.
More information about our utilization review policy and availability can be
found at the Quality Management section of our website.
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.
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