Utilization Management

Capital Health Plan makes health care decisions to ensure quality treatment and efficient use of resources.

Understanding Capital Health Plan's Health Care Decision-Making

CHP reviews medical literature and seeks the input of appropriate specialists to develop clinical review standards for coverage of certain health care services. These clinical guidelines are available to members and participating providers. CHP's participating physicians use the clinical review standards to help determine when a member needs health care services, medication, and supplies, and which services, medication, and supplies are suitable. A primary care physician or participating provider may request that CHP review, for coverage purposes, whether a member meets clinical standards for a specific service, medication, or supply. CHP may also proactively evaluate specific services, medication, or supplies to determine coverage by the member's plan. The requested services and supplies must support the diagnosis and treatment of the member's condition and standards of good medical practice. The review process may be:

  • Urgent (a service that if not quickly decided could seriously jeopardize the member's health or ability to regain maximum function)
  • Pre-Service (approved in advance of obtaining medical care, such as precertification, prior approval, and required authorization)
  • Post-Service (after service is provided)
  • Concurrent Care Decisions (provide continued coverage of approved ongoing treatment while an internal appeal is pending; this situation may also be submitted as Urgent)

If you have questions about utilization management procedures, decisions, or your benefits, you can contact our Member Services Department during business hours. CHP safeguards confidential information and makes disclosures only when allowed under state and federal law, including HIPAA. Information used in the decision-making process is protected by CHP staff members who must use the information.

CHP's policy statement for utilization management decisions:

  1. Utilization management decisions are based only on the appropriateness of care and services according to the clinical standards, and the existence of benefit coverage.
  2. CHP does not reward reviewers or provide financial incentives to deny coverage or care.
  3. CHP does not offer incentives to encourage decisions that result in underutilization.

A member, physician, or person authorized by a member may request a re-evaluation of a utilization management decision as follows:

  • By sending to CHP's Appeal Department a written request to review a previous coverage or payment decision, which is known as an appeal.  Staff collects any necessary documents, and the member request is reviewed by a team of senior managers and physicians. CHP notifies the member in a timely manner of the review group's decision.
  • By requesting an expedited appeal decision. Expedited decisions are only those made when a delay in an appeal decision for care that has not occurred would harm the member's health. A call to Member Services alerts CHP to make an expedited appeal decision. Staff will then notify the member when the decision has been made.
  • By asking for an evaluation by an organization outside of CHP if dissatisfied with the appeal decision.  The Independent Review Organization is an independent organization that is hired by Medicare.  The organization is not connected with CHP and is not a government agency.  The organization is a company chosen by Medicare to review CHP's decisions about Medicare benefits.  Members pay nothing for independent reviews, and CHP must accept decisions made by independent review organizations. The letter that notifies the member of the appeal decision explains how to request an independent review.
  • Review additional information on grievances and appeals

CHP regularly reviews new medical technologies (drugs, procedures, and devices) for coverage. Members and providers may ask at any time for consideration of new technology. To make decisions, CHP's medical director reviews research by relevant specialists and information from government regulatory bodies, Medicare manuals, and medical journals 

The standards for approval include:

  • final acceptance by the proper government regulatory body
  • testing that shows a positive effect on health
  • improved health outcomes at least as helpful as any established option
  • improved outcomes outside the investigational setting

Referrals and Authorizations

It is important to understand the difference between a referral and an authorization, and how to obtain each one. Learn more about the difference between a referral and an authorization.