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Criteria Used for Medical Decision-Making

The Health Management staff utilizes written criteria to assist in the evaluation of medical necessity and appropriateness of care. Information regarding obtaining copies of the criteria and the availability of the Medical Director to discuss medical necessity determinations are available in the provider newsletters and provider manuals. The following criteria are utilized:

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


Last modified 04/07/08