AmericasHealth Plan (AHP) Utilization Management (UM) Department and UM Committee involved in the evaluation and improvement of quality care and services, agree to appropriately approve and deny services and discourage under-utilization.
AHP affirms that:
- UM decision making is based only on appropriateness of care and service and the existence of coverage.
- AHP or its contracted entities, do not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care.
- AHP or its contracted entities do not offer financial incentives to UM decision makers that encourage decisions that result in under-utilization.
- Member healthcare is not compromised.
- Practitioners are ensured independence and impartiality in making referral decisions that will
- Any other similar matters