Requesting a Copy of the Information or Standards Used To Render a Coverage Decision

CPMG's Care Management Team, made up of non-clinical staff, licensed nurses, and medical Directors (pediatric physicians) makes sure that recommendations made by your provider are

• covered by your health plan and
• provided by a physician or in a facility that has been credentialed by CPMG and who is contracted with us.

To do this, CPMG's care management teams reviews requests from providers, as well as medical records, relevant coverage policies developed by your health plan, and, if available, national standards of care. After the CPMG nurses and medical directors (MD) complete their review, they decide whether or not the recommended treatment is "authorized" for coverage under your health plan. If we decide that the service is not covered by your health plan, you and the provider who made the recommendation, will receive a letter explaining how and why we came to our decision. This letter will also tell you how to file an appeal if you disagree with the decision and it informs you that, by calling 1 800 788-9029, you may request a copy of the coverage policy or standard we used to arrive at our decision.

Prior assessment to determine that proposed services, such as hospitalization, diagnostic testing, specialty referral, Physical Therapy, Speech, Home Health, etc., are appropriate for a particular member and will be covered by the Plan. Payment for services depends on whether the member and the category of service are covered by the member's benefit plan.

Providers, members and/or the public may request a copy of the policy and procedure used to authorize, delay, modify or deny services and the UM criteria or guidelines for specific services

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