Medicare Utilization Management

The Health Plan is committed to making the right decision for services that are needed for our members. All requests for services are reviewed by a licensed registered nurse or prior authorization coordinator.  If the request cannot be approved by the nurse, the case is reviewed by a same or similar board certified medical director as the provider requesting the services. Any services that are deemed not approvable are reviewed using Medicare’s Local or National Coverage Determination Criteria or Medicare Content InterQual™ Criteria. If the services requested cannot be reviewed using the previously mentioned options, The Health Plan’s uses internally developed Medical Policies. You have the right to view and/or receive a copy of the criteria or policy used for the review of your services. To receive a copy, you can call The Health Plan’s customer service department at 1.800.624.6961.

Internally Developed Medical Policies 

eviCore Policies

The Health Plan partners with eviCore healthcare (eviCore) to review requests for certain services for medical necessity and appropriateness on behalf of The Health Plan Medicare Members. 

Click here to access eviCore's Clinical Guidelines.

Last Modified: May 16, 2024 at 9:39 AM