In accordance with the provisions of the member’s health plan, all
utilization review decisions are based on:
- the member’s health plan benefits;
- Independence’s definition of medical necessity, including but not
limited to the most cost-effective setting for the requested services;
- the appropriateness of the requested care, services, and/or supplies;
and
- the member’s coverage at the time care, services, and/or supplies are
requested and provided.
Only licensed physicians may make denials of coverage of health care
services and/or supplies based on lack of medical necessity during a
utilization review.
The Independence physician medical directors and independent physician
medical consultants who perform utilization review services for Independence
are not compensated or given incentives based on their coverage decisions.
Contracted external physicians are compensated on a per-hour or
per-case-reviewed basis, regardless of the coverage determination. Independence
does not provide financial incentives to internal or external physicians
performing utilization review services for issuing denials of coverage.
Providers are required to enter all routine authorization requests through
the Authorizations transaction on the NaviNet® web portal
(NaviNet Open). If there are any requests that require immediate review or
involve members with coverage through the Federal Employee Program or if
NaviNet Open is not available, providers can call 1-800-ASK-BLUE
(1-800-275-2583). Facilities can also call
1-800-ASK-BLUE (1-800-275-2583) for ambulance and discharge
planning needs.
NaviNet® is a registered
trademark of NantHealth, an independent company.