Utilization Management Policy
Disclosure Notice
Providence is delegated the responsibility for Utilization Management from
contracted managed care (HMO) health plans. Providence follows the clinical
guidelines set forth by Medicare and contracted health plans. The guidelines
provided are used by Providence Medical Foundation to authorize, modify,
or deny care for persons with similar illnesses or conditions. Specific
care and treatment may vary depending on individual need and benefits
covered under your plan. In situations there is no available guidelines
from the health plan, the delegated entity may adopt internal coverage
policies approved by the health plans. Adopted internal coverage policies
will comply with CMS guidance (refer to CMS Manual Chapter 4 section 90.5)
MCM Chapter 4 (cms.gov) and are updated based off evidence-based guidelines
and research. They are publicly accessible under Internal Coverage Guidelines
(coming soon).
- Providence Medical Foundation will disclose a list of network providers
to members, upon request.
- Utilization Management medical clinical guidelines are disseminated to
members and practitioners upon request.
- All Utilization Management decisions are based on appropriateness of care
and service.
- Providence Medical Foundation does not compensate practitioners for individual denials.
- Providence Medical Foundation does not offer incentives to encourage denials.
- Providence Medical Foundation does not have the financial incentives that
would encourage decisions that would impact under/over-utilization of
care, service or available member benefits.
For questions or concerns that are related to a referral that your provider
has submitted, patients can telephone our main Utilization Management number:
855-359-6323. Hearing or speech-impaired members (TTY users) can call 711 relay services.
Collect calls are accepted for patient referral matters, and Spanish speaking
staff members are available.