All associates who make utilization management decisions are required to adhere to the following principles:

  • Utilization management decision making is based only on appropriateness of care and service and existence of coverage.
  • We do not specifically reward practitioners or other individuals for issuing denials of coverage or care. Decisions about hiring, promoting or terminating practitioners or other staff are not based on the likelihood or perceived likelihood that they support or tend to support denials of benefits.
  • Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization or create barriers to care and service.

 

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Featured In:
June 2019 Anthem Blue Cross Provider Newsletter - California