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How Utilization Management Decisions Are Made

  • Managed Care Providers/Practitioners/Employees

-UM decisions are based only on appropriateness of care, service and existence of coverage.

-HealthTexas does not reward practitioners or other individuals for issuing denials of coverage.

-Financial incentives are not rewarded on decisions that result in underutilization.

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.

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The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual needs and the benefits covered under your contract.