Utilization Management Policies

Learn more about Humana Behavioral Health policies for discussing utilization management denial decisions and decisions about appropriateness of care.

Discussing Utilization Management Denial Decisions

Humana Behavioral Health provides practitioners with the opportunity to discuss any utilization management denial decision based on medical necessity or clinical appropriateness with a licensed, board certified psychiatrist or another appropriate doctoral-level behavioral health reviewer. To schedule a discussion with a reviewer, please contact the Humana Behavioral Health telephone number on the back of the enrollee’s insurance card. You may also call our help line at 1-800-777-6330. A customer service representative will connect you to a case manager who will schedule the discussion.

Affirmative Statement Regarding Incentives

Humana Behavioral Health certification decisions are based only on the appropriateness of care and service, as well as the existence of coverage. Humana Behavioral Health does not reward physician reviewers, case managers, employees, practitioners, or other individuals for issuing denials of coverage or service. Humana Behavioral Health does not pay incentives to physician reviewers, employees, practitioners, or Other individuals to reduce the provision of care which is deemed medically necessary. Humana Behavioral Health does not give financial incentives to physician reviewers, case managers, employees, practitioners, or other individuals to encourage decisions that result in underutilization of care or services.

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Process for Member Initiation of an Appeal

Including a description of the availability of an independent external

appeal of a utilization management decision made by Humana Behavioral Health

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