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 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 underutilization.