In accordance with the provisions of the member?s health plan, all
utilization review decisions are based on:
- the member?s health plan benefits;
- Independence?s definition of medical necessity, including but not limited
to the most cost-effective setting for the requested services;
- the appropriateness of the requested care, services, and supplies;
- and the member having active coverage at the time care, services and
supplies are requested and/or provided.
Note: Only licensed physicians may make denials of coverage of health
care services and supplies based on lack of medical necessity during a
utilization review.
The Independence physician medical directors and independent physician
medical consultants who perform utilization review services for Independence
are not compensated or given incentives based on their coverage decisions.
Contracted external physicians are compensated on a per-hour or
per-case-reviewed basis, regardless of the coverage determination. Independence
does not provide financial incentives to internal or external physicians
performing utilization review services for issuing denials of coverage.
Providers are required to enter all routine authorization requests through
the Authorization transaction on 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.