Referrals

HealthTexas Medical Group makes this impartiality statement that providers/specialists/employees are ensured independence and impartiality in making referral decision with no impact on hiring, compensation, termination, promotion, and any other similar matters.

All coverage determinations (approvals and denials) are reviewed by licensed staff and made based on member eligibility at the time of services, medical necessity, appropriateness of care and services and the availability of existing benefit coverage of the Member’s selected health plan and benefit package. To determine medical necessity, specific criteria are applied to the information supplied by the requesting provider. UM Staff is available for additional collaboration with practitioners and members when applicable by calling the customer services number. The reviewer must also evaluate if relevant clinical information has been supplied by the requesting provider and then take into consideration the following factors: individual characteristics such as: age, co-morbidities, complications, progress in treatment, psychosocial situation, and home environment, when applicable.

HTMG uses Medicare Guidelines (National Coverage Determinants and Local Coverage Determinants), UHC guidelines for Part B medications, and MCG 28th edition for requests not covered in Medicare Guidelines. These guidelines may have some differences in recommendations. Information contained in the guidelines is not a substitute for a physician’s or other healthcare professional’s clinical judgment and is not always applicable to an individual. Therefore, the physician or healthcare professional and patient should work in partnership in the decision-making process regarding the patient’s treatment. Furthermore, using this information will not guarantee a specific outcome for each patient. None of the information in the guidelines is intended to interfere with or prohibit clinical decisions made by a treating physician or other healthcare professional regarding medically available treatment options for patients.