Denver Health Medical Plan, Inc. (DHMP) has published internal clinical coverage criteria for the following services:
DHMP considers the member’s medical needs by using established health care guidelines based on medical evidence and state regulations to determine the appropriate frequency and/or quantity of the service(s) requested. The DHMP Physician Reviewer reviews all requests that do not meet these criteria
The coverage policies apply to the benefit plans administered by DHMP and may not be covered by all DHMP plans. Please refer to the member’s benefit document for specific coverage information. If there is a difference between this general information and the member’s benefit document, the member’s benefit document will be used to determine coverage. For example, a member’s benefit document may contain a specific exclusion related to a topic addressed in a coverage policy.
Coverage determinations for individual requests require consideration of:
- The terms of the applicable benefit document in effect on the date of service
- Any applicable laws and regulations
- Any relevant collateral source materials including coverage policies
- The specific facts of the request