Utilization Management

UNDERSTANDING CHP'S HEALTH CARE DECISION-MAKING

CHP and its participating physicians use clinical review standards to determine when a member needs health care services and supplies, and which services and supplies are suitable. The requested services and supplies must support the diagnosis and treatment of the member's condition and standards of good medical practice. The review process may be pre-service (before services are provided), concurrent (based on an urgent request to continue a hospital stay), or post-service (after services are provided).

If you have questions about utilization management procedures, decisions or benefits, you can contact our Member Services Department at (850) 383-3311 or toll-free at 1-877-247-6512, Monday through Friday from 8:00 am through 5:00 pm. The TDD number for the hearing impaired is (850) 383-3534. If you call after hours or on a weekend, you can call (850) 383-3333 or toll-free (800) 390-1434. The after-hours number for the Florida State Relay, for the hearing impaired is (800) 955-8771.

CHP safeguards confidential information and makes disclosures only when allowed under state and federal law, including HIPAA. Information used in the decision-making process is protected by CHP staff members who must use the information.
CHP's policy statement for utilization management decisions:

1. Utilization management decisions are based only on the appropriateness of care and services, and the existence of benefit coverage.
2. CHP does not reward reviewers or provide financial incentives to deny coverage or services.
3. CHP does not offer incentives to encourage decisions that result in underutilization.

A member, physician, or a person authorized by a member may request a re-evaluation of a utilization management decision as follows:

• By sending to CHP's Grievance Department a written request for reconsideration, which is known as a grievance. Staff collects any necessary documents, and the member request is reviewed by a group of senior managers and physicians. CHP notifies the member in a timely manner of the review group's decision.

• By requesting an expedited grievance decision. Expedited decisions are those made when a delay in a grievance decision for care that has not occurred would harm the member's health. A call to Member Services at (850) 383-3311 alerts CHP to make an expedited grievance decision. Staff will then notify the member when the decision has been made.

• By asking for an evaluation by an organization outside of CHP if dissatisfied with the grievance decision. An "Independent review organization" evaluates the request, and has no financial or business ties to CHP. Members pay nothing for independent reviews, and CHP must accept decisions made by independent review organizations. The letter that notifies the member of the grievance decision explains how to request an independent review.