Annual Affirmative Statement About Incentives
Declares Denver Health Medical Plan's Utilization Management (UM) program principles about decision-making and incentives that affect member access to care. Applies to DHMP UM staff and related decision-making processes.
No material clinical or coverage changes in this revision.
Coverage Criteria
DHMP affirms that UM staff or other individuals are not rewarded or otherwise incentivized to issue denials of coverage or services. The plan does not maintain practices that create financial incentives for UM decision-makers to deny care. If you have questions about these safeguards, contact DHMP Medical Management or Compliance at 1-800-700-8140.
Provider Actions and UM Decision Principles
UM determinations use evidence-based guidelines
UM determinations are performed by a team of licensed health care professionals using nationally recognized, evidence-based clinical guidelines and applicable community standards when evaluating medical necessity.
Providers should expect UM decisions to
Providers should expect Utilization Management (UM) decisions to be based solely on the appropriateness of the requested care and the member's contract benefits, taking into account the member's clinical context and community standards.
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