Utilization Review Process: What You Need to Know

Date: 11/08/22

Superior HealthPlan ensures that all medical decisions are equitable, necessary and in the best interest of our members. To assist with ensuring quality care is provided, Superior’s Utilization Management Department monitors, identifies and evaluates health-care services delivered to members.

Determinations made by Superior’s Utilization Management Department are based on existing coverage, as well as the medical necessity and appropriateness of the care or service. Superior considers unique circumstances such as members’ age, comorbidities, local delivery system and the availability of the requested services with a participating Superior provider, when making determinations. Utilization Management strives to improve member outcomes through the optimal use of facilities and services.

Utilization review decisions are made in accordance with currently accepted medical or health-care practices and regulatory requirements, while taking into consideration the individual member needs and complications at the time of the request, in addition to the local delivery system available for care. Utilization Management criteria and clinical policies are reviewed at least annually and updated as appropriate, with the involvement from physicians who are a part of Superior’s Utilization Management Committee. Utilization review criteria are not intended to be a substitute for physician judgment. Superior clinical policies are posted on Superior’s Clinical, Payment & Pharmacy Policies webpage.

Superior uses evidence-based, clinical-decision support tools such as policy criteria and Change Healthcare’s InterQual® criteria. These criteria are nationally recognized and evidence-based and used to review the medical necessity of inpatient hospital admissions, surgeries, outpatient procedures, durable medical equipment and ancillary services.

Requested services can only be denied by board certified physicians. The most common reason for denial is lack of sufficient documentation to support medical necessity. Providers may discuss medical or behavioral health Utilization Management denial decisions with a Superior Medical Director by contacting Superior’s Utilization Management Department. The criteria used to make specific determinations are available to providers upon request.

Please note: Superior does not reward providers or other individuals for issuing denials of coverage. Financial incentives for Utilization Management decision makers do not encourage decisions that result in underutilization.

Providers can contact Provider Services at 1-877-391-5921 to request a copy of the criteria used to make a specific decision.