Utilization Managment Standards and Criteria

Criteria used to make utilization decisions are available in the online Behavioral Health Provider Manual located in the Provider Center at priorityhealth.com/provider/manual/. You can get to it from the green menu bar at the top of the page, or under Working With Us in the Provider Center home page. In addition, your agency or facility may request a copy of the Behavioral Health Department’s Standards and Criteria for Utilization Management. Questions about behavioral health-related utilization decisions or a copy of the utilization management criteria can be requested by contacting Behavioral Health case managers at 800 673-8073 daily 8:30 a.m - 5:00 p.m. Monday through Friday.

Utilization Decisions
We make every effort to make utilization decisions that are fair and consistent in order to serve the best interest of our members. That is why we:

• make utilization decisions based only on appropriateness of care and service, as well as existence of coverage
• do not compensate or reward practitioners or other individuals conducting utilization review for denial of coverage or service
• do not offer financial incentives for utilization decision-makers to encourage denial of coverage or service
• decide on coverage of new technology after comprehensive research and careful review by our Board Certified Psychiatrists
• provide information about the Utilization Management Process and the authorization of care

If you have a question regarding general or specific utilization management decisions or process, please contact the Behavioral Health department. A case manager will assist you with your questions and refer you to a Board Certified Psychiatrist.