Criteria used for medical decision-making
The Health Management staff use written criteria to help evaluate medical necessity and appropriateness of care. Providers can obtain copies of the criteria and learn how to contact the Medical Director to discuss medical necessity determinations; check our provider newsletter for instructions.
We use these criteria:
Utilization decisions structured for appropriate patient care
Priority Health makes every effort to make utilization decisions that are fair and consistent in order to serve the best interests of the member. That is why we:
- Will make utilization decisions based only on appropriateness of care and service, as well as existence of coverage
- Will not compensate practitioners or other individuals conducting utilization review for denial of coverage or service
- Will not offer financial incentives or rewards for utilization decision-makers to encourage denial of coverage or service
- Will decide on coverage of new technology after comprehensive research and review by the chief medical officer and physician committees
