Utilization Management Policy for Dental Benefits
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Defines Astiva Health's utilization management (UM) processes, governance, and safeguards for dental benefits and applies to internal and external customers, vendors, contracted IPAs, practitioners, and providers involved in UM decisions.
Policy was approved by the Utilization Management Committee on 12/6/2023.
Coverage and Medical Necessity Criteria
Operational UM Coverage Criteria
Covered when ALL of the following operational principles are met
Operational safeguards include annual affirmation statements signed by UM staff and regular communications to providers.
This policy does not list any explicit clinical exclusions. Instead, coverage determinations are governed by the plan’s utilization management (UM) operational principles that emphasize the appropriateness of care and the existence of coverage. The document focuses on UM process, oversight, and safeguards (for example, monitoring for over- and under-utilization and annual affirmation statements for UM staff) rather than enumerating specific services or conditions that are categorically excluded.
The policy does not define a list of conditions or services that are explicitly deemed Not Medically Necessary (NMN). Rather, NMN determinations are implied to arise from UM decisions when requested care is not appropriate or is not covered under the member’s benefits. UM referral decisions are therefore based on assessment of appropriateness of care and existence of coverage, and NMN conclusions follow from those assessments.
Provider Requirements, Prior Authorization, and Documentation
Prior authorization and referral review requirement
UM referral decisions must evaluate both the appropriateness of the care or service and the existence of coverage; practitioners and contracted providers participating in UM must follow the plan's referral and review processes.
Provider obligations for utilization management
Providers and contracted practitioners must follow the plan procedures for UM and ensure they do not receive or act on financial incentives tied to issuing denials.
- Follow plan referral and review processes for UM decisions.
- Do not accept financial incentives that could lead to under- or inappropriate utilization.
- Sign annual affirmation statements regarding incentives (UM staff).
Documentation and audit requirements
Providers and UM staff must document that referral decisions are based on appropriateness of care and existence of coverage; UM activity is monitored through measurements and audits.
- Document rationale that care is appropriate and covered for each referral decision.
- Support documentation used in monitoring (turnaround time audits, inter‑rater reliability surveys, denial/appeal turnaround audits).
- Ensure members are informed of grievance and appeals processes when adverse actions occur.
Denial governance and incentive safeguards
Denials must not be issued for reasons of fiscal incentive; UM referral decisions are based only on appropriateness of care and existence of coverage.
- UM decision makers and Plan contracted providers must not receive financial incentives that result in under- or inappropriate utilization.
- Annual affirmation statements on incentives are required for UM staff.
- Monitoring mechanisms exist to detect over- and under-utilization and protect against incentive-driven denials.
Policy Purpose and Scope
This is an administrative and governance-focused UM policy for dental benefits that establishes the principles and safeguards used to make utilization decisions. Key operational principles state that UM referral decisions are based solely on the appropriateness of care and the existence of coverage, and that UM decision-makers and contracted providers must not receive financial incentives that create under- or inappropriate utilization. Oversight and quality mechanisms are documented, including annual incentive affirmation statements for UM staff, provider notification processes, measurement for over- and under-utilization, and audits such as inter-rater reliability and turnaround time reviews. The policy also ensures members are informed of grievance and appeals processes and that internal procedures enable grievances, appeals, and fair hearings for adverse actions or inactions.
Acronyms and Definitions
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