Peach State Health Plan does not reward practitioners, providers, or employees who perform utilization reviews, including those of the delegated entities for issuing denials of coverage or care. UM decision making is based only on appropriateness of care, service, and existence of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. Utilization denials are based on lack of medical necessity or lack of covered benefit.
Peach State and its delegated health plan partners have utilization and claims management systems in place in order to identify, track, and monitor the care provided and to ensure appropriate healthcare is provided to the members.
Peach State has implemented the following measures to ensure appropriate utilization of health care: