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UAHC Health Plan of Tennessee affirms its compliance with 42 CFR 438.6(h), and 42
CFR 422.208, that compensation to individuals or entities that conduct utilization
management activities is not structured so as to provide incentives for the individual
or entity to deny, limit, or discontinue medically necessary services to any enrollee, as
provided by the Balanced Budget Act of 1997 and the provisions of 42 CFR
438.210(e).
UAHC does not subcontract for utilization management activities. Employees of
United American of Tennessee that conduct utilization management activities are not
provided incentives for the individual or entity to deny, limit, or discontinue medically
necessary services to any enrollee. UAHC/UTAN does not reward practitioners or
other individual for issuing denials of coverage or service care.
UAHC affirms that Utilization Management decision-making is based only on
individualized determinations of medical necessity, appropriateness of care and
service and existence of coverage.
UAHC/UATN does not employ, and shall not permit others acting on behalf of the
Plan to employ utilization control guidelines or other quantitative coverage limits,
whether explicit or de facto, unless supported by an individualized determination of
medical necessity based upon the needs of each enrollee and his/her medical
history.
Compensation to employees of UAHC/UATN that conduct utilization management
activities is not structured so as to provide incentives for the individual or entity to
deny, limit, or discontinue medically necessary services to any enrollee that could
result in under-utilization.
If you have any questions about this information, you may call our toll free number –
1-800-876-5242.
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