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Required Annual Notification on UM decisions

December 27, 2010

Annual Utilization Management Notifications

Financial Incentives:
It is the policy of Health First Network to inform practitioners, providers and staff who make utilization-related decisions of the need for special concern about the risks of under-utilization. HFNI will maintain a policy and distribute a statement to all its practitioners, providers and employees (also to health plan members if HFNI has member services delegation) which affirms that:

UM decision-making is based only on appropriateness of care and service.

HFNI does not compensate practitioners or other individuals conducting utilization review for denials of coverage or service. HFNI does recognize the skill, knowledge, expertise, and time constraints of Physician consultants. As a Provider Organization, HFNI does compensate UM consultants for their time and expertise in performing a review. This compensation is provided to a HFNI UM Consultant/Specialist for the time spent on the review, and is not related to the determination made.

Financial incentives for UM decision-makers do not encourage denials of coverage or services.

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