Utilization Review Process: What You Need to Know

Date: 09/25/20

Determinations made by the Utilization Management (UM) Department are based on existing coverage, as well as the medical necessity and appropriateness of the care or service. To assist with ensuring quality care is provided, Superior’s UM Department monitors, identifies and evaluates health-care services delivered to members.

UM strives to improve member outcomes through the optimal use of facilities and services. When making determinations, Superior considers unique circumstances such as members’ age, comorbidities, local delivery system and the availability of the requested services with a participating Superior provider.

Superior uses evidence-based, clinical-decision support tools such as Change Healthcare’s InterQual® criteria. These criteria are nationally recognized, evidence-based and are used to review the medical necessity of inpatient hospital admissions, surgeries, outpatient procedures, durable medical equipment and ancillary services. To learn more about the criteria, please visit Change Healthcare’s website.

Utilization review decisions are made in accordance with currently accepted medical or health-care practices, while taking into consideration the individual member’s needs and complications at the time of the request, in addition to the local delivery system available for care. UM criteria and clinical policies 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 not intended to be a substitute for physician judgment. To review Superior’s clinical policies, please visit Superior’s Clinical and Payment Policies webpage.

Requested services can only be denied by doctors. The most common reason for denial is lack of sufficient documentation to support medical necessity. Providers may discuss medical or behavioral health UM denial decisions with a Superior Medical Director by contacting Superior’s UM Department. The 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 a UM decision, request criteria or for additional details on the information mentioned above, please contact the Utilization Management Department (available Monday to Friday 8:00 a.m. to 5:00 p.m. local time).

• Medicaid (STAR, STAR+PLUS, STAR Health and STAR Kids), CHIP and STAR+PLUS Medicare-Medicaid Plan (MMP): 1-800-218-7508
• Ambetter from Superior HealthPlan (Marketplace): 1-877-687-1196

For after hours, state-approved holidays and weekends, calls are answered by Superior’s 24-hour Nurse Advice Line.