Utilization Management Policy

Disclosure notice

Providence is delegated the responsibility for Utilization Management from contracted managed care (HMO) health plans. Providence follows the clinical guidelines set forth by Medicare and contracted health plans. The guidelines provided are used by Axminster Medical Group and Providence Medical Associates to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and benefits covered under your plan. In situations there is no available guidelines from the health plan, the delegated entity may adopt internal coverage policies approved by the health plans. Adopted internal coverage policies will comply with CMS guidance (refer to CMS Manual Chapter 4 section 90.5) MCM Chapter 4 (cms.gov) and are updated based off evidence-based guidelines and research. They are publicly accessible under Internal Coverage Guidelines.

• Axminster Medical Group and Providence Medical Associates will disclose a list of network providers to members, upon request.
• Utilization Management medical clinical guidelines are disseminated to members and practitioners upon request.
• All Utilization Management decisions are based on appropriateness of care and service.
• Axminster Medical Group and Providence Medical Associates does not compensate practitioners for individual denials.
• Axminster Medical Group and Providence Medical Associates does not offer incentives to encourage denials.
• Axminster Medical Group and Providence Medical Associates does not have the financial incentives that would encourage decisions that would impact under/over-utilization of care, service or available member benefits.

For questions or concerns that are related to a referral that your provider has submitted, patients can telephone our main Utilization Management number: 855-359-6323. Hearing or speech-impaired members (TTY users) can call 711 relay services. Collect calls are accepted for patient referral matters, and Spanish speaking staff members are available.