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In accordance with the benefits available under the member?s health plan
and Independence?s definition of medical necessity, it is our policy that all
utilization review decisions are based on the appropriateness of care,
services, supplies, and existence of coverage. Only licensed 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 Independence
are not compensated or given incentives based on their coverage decisions.
Medical directors and nurses are salaried employees. 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 required to enter all routine requests for authorization
through the NaviNet? web portal. If there are any requests that
require immediate review or involve members with coverage through the Federal
Employee Program, or if NaviNet is not available, providers can call
1-800-ASK-BLUE. Facilities can also call 1-800-ASK-BLUE for
ambulance and discharge planning needs.
NaviNet is a registered trademark of NaviNet, Inc., an
independent company.
]