Utilization management decisions
Affirmative statement regarding physician incentives for utilization management decisions
It is the policy of AmeriHealth New Jersey and its affiliates ("plans") that all utilization review decisions are based on the appropriateness of health care services and supplies, in accordance with the plans' definition of medical necessity and the benefits available under the member's coverage. Only physicians can make denials of coverage of health care services and supplies based on lack of medical necessity.
The nurses, medical directors, other professional providers, and independent medical consultants who perform utilization review services for the plans are not compensated or given incentives based on their coverage review decisions. Medical directors and nurses are salaried employees of the plans, and contracted external physicians and other professional consultants are compensated on a per-case-reviewed basis, regardless of the coverage determination. The plans do not specifically reward or provide financial incentives to individuals performing utilization review services for issuing denials of coverage. There are no financial incentives for such individuals that would encourage utilization review decisions that results in underutilization.