In accordance with the benefits available under the member?s health plan and our definition of medical necessity, it is our policy that all utilization review decisions are based on the appropriateness of health care services and supplies.

Only physicians may make denials of coverage of health care services and supplies based on lack of medical necessity. The nurses, medical directors, other professional providers, and independent medical consultants who perform utilization review services for us are not compensated or given incentives based on their coverage decisions. Medical directors and nurses are salaried employees, and contracted external physicians and other professional consultants are compensated on a per-case reviewed basis, regardless of the coverage determination. We do not reward or provide financial incentives to individuals performing utilization review services for issuing denials of coverage. There are no financial incentives for such individuals that would encourage utilization review decisions that result in underutilization.