Utilization Management – Authorization and Referrals
CHP makes decisions about coverage for health care services with two main goals as its focus: to cover quality treatment with the efficient use of resources. CHP's participating physicians coordinate preventive care and specialty services for their patients. CHP evaluates new technologies and develops clinical treatment tools to guide the care of members. This is called "utilization management."
Capital Health Plan reviews medical literature and seeks the input of appropriate specialists to develop clinical review standards for coverage of certain health care services. These clinical guidelines are available to members and participating providers. CHP's participating physicians use the clinical review standards to help determine when a member needs health care services, medication and supplies, and which services, medication and supplies are suitable. A primary care physician or participating provider may request that CHP review, for coverage purposes, whether a member meets clinical standards for a specific service, medication or supply. CHP may also proactively evaluate specific services, medication or supplies to determine coverage by the member's plan. The requested services and supplies must support the diagnosis and treatment of the member's condition and standards of good medical practice.
Authorizations are subject to a member's eligibilty, enrollment status and covered benefits. An authorization for services does not apply if benefit limits have been reached.