Denver Health Medical Plan, Inc. (DHMP) has a Utilization Management (UM) program to ensure that members have access to quality health care. The program utilizes a team of health care professionals to evaluate the medical necessity of the services by using nationally recognized, evidence-based clinical guidelines and community standards. The decision are based on the appropriateness of care and services available to members within their contracted benefits. DHMP affirms the following Utilization Management program practices:
- UM decision-making is based only on the appropriateness of the care and services requested and the existing coverage and benefits available to the members;
- UM staff are not rewarded or otherwise incentivized to issue denials of coverage or services; and,
- UM decision-making staff members do not receive financial incentives that encourage decisions resulting in underutilization.