All aspects of the UM program including documents, findings, and Utilization Management Committee (UMC) minutes are confidential and protected from disclosure under CMS Regulations, and State and Federal Law. All persons, employees, and committee members must understand and agree to comply with confidentiality policies and sign a Confidentiality Agreement. Identifiable patient information will be managed according to the approved HIPAA and health plan privacy policies.

Decisions regarding requests for medical care are based only on appropriateness of care and service and existence of coverage. Practitioners and other individuals are not specifically rewarded for issuing denials of coverage or care. Compensation for individuals who provide utilization review services does not contain incentives, direct or indirect, for these individuals to make inappropriate review decisions.

A conflict of interest, which might impair objectivity in any review or decision process, the physician shall not participate in any deliberation involving such issues and shall not cast a vote or any related issues. Decision-making is based only on appropriateness of care and service and existence of coverage. No person in the review process will review cases in which they were actively or personally involved. If a potential for conflict of interest is identified, another qualified reviewer will be designated.

Imperial Health Holdings Medical Group complies with national coverage decisions, general Medicare coverage guidelines (i.e. CMS guidelines, NCD/LCD and applicable health plan guidelines).

Utilization review criteria, based on reasonable medical evidence and acceptable medical standards of practice such as Milliman Care Guidelines (MCG), and applicable health plan guidelines, are used to make decisions pertaining to the utilization of services. Review criteria are used in conjunction with professional medical judgment, which considers the needs of the individual patient and characteristics of the local delivery system.

IHHMG makes the UM Criteria available to its Members, Practitioners and the Public upon written request.