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 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. 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, 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. More information about our utilization review
policy and availability can be found on our website.
NaviNet is a registered trademark of NaviNet, Inc., an
independent company.