Brand New Day has a Utilization Management 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 decisions are based on the appropriateness of care and services available to members within their contracted benefits. Brand New Day affirms the following Utilization Management program practices:
Brand New Day receives numerous requests for authorization for coverage of medical services. If the review involves a clinical issue, no one other than a physician can make a determination to deny coverage for the services requested. In all instances, our physician reviewers and medical directors welcome direct contact with the treating physician to promote a dialogue regarding medical and/or hospital services that are requested.
Criteria used for a specific review decision is made available to providers, members and the public upon request to the Brand New Day Member Services Department.
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