Notice to Providers Regarding the Plan's Utilization Management (UM) Policies and Procedures

Helping Members Make the Most of Their Benefits

It is important for all members to know about the Plan's decision-making policies. Many members have questions about their benefits and how the Plan decides what benefits are authorized for payment.

We hope you will join us in reminding members of the following important points:

• The purpose of UM is to validate that services are medically necessary and covered by the Plan.
• Passport Health Plan and Passport Advantage do not reward anyone, including practitioners, for denying services to members.
• The Plans do not compensate associates or practitioners to make decisions that keep members from getting the care they need.

Like you, our first concern is that members receive appropriate care in a timely manner. Therefore, if members who visit your office have questions about the UM process or benefit decisions, please refer them to Member Services at 1-800-578-0603 (TTY/TDD 1-800-691-5566). We will be happy to assist them.

UM Department Contact Information

Remember, you can contact our Utilization Management department at any time! Call (800) 578-0636 between the hours of 8:00 a.m. and 5:30 p.m., Monday through Friday. If you call after hours, please leave a message.

Send a fax to (502) 585-8204 for Home Health, (502) 585-8205 for Therapies and Pain Management, (502) 585-8207 for Retrospective Reviews, (502) 585-7990 for DME, or (502) 585-7989 for all other requests.

Clinical Criteria Available to Providers

Utilization Management (UM) strives to ensure our members use their benefits as needed and as appropriate. To assist us, we use Milliman Care Guidelines®, InterQual® Criteria, Medicare, and/or Medicaid criteria/guidelines to evaluate the necessity of medical services. These guidelines support the delivery of quality health care and assist us in evidence-based clinical decision making and reviewer consistency.

In addition, we utilize Passport Health Plan (PHP) / Passport Advantage (PAD) medical policies in the decision making process. We involve actively practicing providers with like or similar expertise in the adoption of criteria, the development of policies, and the review of procedures for applying the criteria.

Copies of PHP/PAD medical policies are available to providers upon request by calling (800) 578-0636. They are also available on the Plan's web site, www.passporthealthplan.com/providercenter.

Need to Talk About Denials?
Call Utilization Management's Medical Directors

Passport Health Plan (PHP) and Passport Advantage (PAD) providers may speak with Medical Directors regarding Utilization Management (UM) decisions and specific cases or service requests at any time. If you disagree with a UM decision, you can discuss the decision by telephone with the medical director who rendered it.

Whenever a denial is verbally issued, the UM staff provides the name, telephone number, and title of the Medical Director who rendered the decision. The provider may then call the Medical Director directly to discuss the denial. Appeals information is included with each denial letter.

If you have questions about the UM process or a UM issue, please call (800) 578-0636.