Network Health utilizes criteria to determine the appropriateness of services requested. You may request to review the criteria prior to a utilization management (UM) decision, or in the event of a denial, in the following ways:

• Via telephone: A clinician will read the criteria over the telephone to you.
• Mail/Fax: We will mail a paper copy to you of the criteria we utilized to make the decision.
• On-site review: You may request an on-site review of the criteria. If our clinical or administrative staff receives such a request, the staff member forwards the call to the manager or director of the department who will speak directly to you. The manager or director will instruct you to complete the Availability of UM Criteria to Practitioner/Request for On-site Visit Form. Once we receive the written request, the manager or director will schedule an appointment with you to come on site to review the criteria we utilized to make the UM decision. During the scheduled visit, we will review with you the criteria online via our CCMS system. You also have the right to request a physician-to-physician meeting at this time to discuss the criteria further.

We document all requests and visits within our CCMS system.