Utilization Review Process: What You Need to Know

Date: 09/30/19

Superior ensures that all medical decisions are equitable, necessary and in the best interest of members. To assist with ensuring quality care is provided, Superior’s Utilization Management (UM) Department monitors, identifies and evaluates health-care services delivered to members.

Determinations made by the UM Department are based on existing coverage, as well as the medical necessity and appropriateness of the care or service. Superior considers unique circumstances such as age, complications, comorbidities, local delivery system and the availability of the requested services with a participating Superior provider, when making determinations. UM strives to improve patient outcomes and optimal use of facilities and services.

During the utilization review process, Superior’s UM Department determines the type and level of treatment a patient will receive based on UM criteria that are nationally recognized, evidence-based standards of care and include input from recognized medical experts. Superior uses evidence-based, clinical-decision support Change Healthcare’s InterQual® utilization review criteria. This criteria covers medical and surgical admissions, outpatient procedures, referrals to specialists and ancillary services.

Utilization review decisions are made in accordance with currently accepted medical or health-care practices, while taking into consideration the individual member needs and complications at the time of the request, in addition to the local delivery system available for care. UM criteria and the policies for application are reviewed at least annually and updated as appropriate, with the involvement from physicians who are a part of Superior’s UM Committee. Utilization review criteria are utilized as an objective screening guide and are not intended to be a substitute for physician judgment. 

When services are evaluated and denied for a member by UM, they are denied only by doctors and are typically denied due to insufficient documentation or a lack of supporting documentation to determine medical necessity, benefit limitations or non-covered benefits. Providers may discuss medical or behavioral health UM denial decisions with a physician or other appropriate reviewers of an adverse determination by contacting Superior’s UM Department. Criteria used to make specific determinations are available to providers upon request.

Please note: Superior does not reward providers or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

To discuss UM decision, request criteria or for additional details on the information mentioned above, please contact Provider Services at 1-877-391-5921 (available Monday to Friday 8:00 a.m. to 5:00 p.m. local time). For after hours, state-approved holidays and weekends, calls are answered by Superior’s 24-hour Nurse Advice Line.