Utilization Management Criteria
Utilization Management (UM) decision making is based only on appropriateness of care and service and existence of coverage. Sanford Health Plan does not specifically reward practitioners or other individuals conducting utilization review for issuing denials of coverage or service care.
Any financial incentives offered to UM decision makers do not encourage decisions that result in under-utilization and do not encourage denials of coverage or service. Decision makers sign an “Affirmative Statement Regarding Incentives” verifying the above conditions.
Utilization Management criteria are available by contacting Utilization Management between 8 a.m. and 5 p.m. Monday through Friday CT, at (800) 805-7938 or emailing at email@example.com.