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Affirmative statement for financial incentives

Coverage determinations and utilization management (UM) 

Visit us online to view a copy of your Provider Manual as well as information on the following: 

  • We use evidence-based clinical guidelines from nationally recognized authorities to make UM decisions. We review requests for coverage to see if members are eligible for certain benefits under their plan. The member, member’s representative or a provider acting on the member’s behalf may appeal this decision if we deny a coverage request.  
  • Our UM staff helps members access services covered by their benefits plans. We don’t pay or reward practitioners or individuals for denying coverage or care. We base our decisions entirely on appropriateness of care and service and the existence of coverage. Our review staff focuses on the risks of underutilization and overutilization of services.