Peach State does not reward or pay its network of providers, or employees for completing utilization reviews. Peach State does not pay its network providers or employees to deny reviews. Utilization decisions are based on the following reasons:
- Services are medically needed.
- Services are covered in the member’s plan.
Our Utilization and Claims Management systems allow Peach State and its partners to:
- And monitor the care given
This process ensures that you (member) receive the right healthcare.
Peach State cares about your health and wants you to get better. Peach State uses certain methods to make certain that you receive the best healthcare for your condition. Those processes are listed below:
- Watch for under and over use of services. Best course of action is taken if this occurs.
- A system in place to support the study of utilization statistics
- Detect possible quality of care issues
- Put into action intervention plans
- And assess the success of the actions taken
- A process to support continuity of care across the health care field
If you need help understanding this information, call the Member Services department at 1-800-704-1484 or TDD/TYY 1-800-255-0056.