Utilization Management

Brand New Day Health Plan 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 decisions are based on the appropriateness of care and services available to members within their contracted benefits. Brand New Day Health Plan 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.

Clinical Issues are Reviewed and Determined by Doctors. 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. Appropriate Care is facilitated between Brand New day and its members through the following guidelines:

  • Utilization decisions are based only on appropriateness of care and service.
  • No person involved in the authorization process may receive compensation for denial of care.
  • No person involved in the authorization process may receive an incentive wither financial or non-financial, directly or indirectly to encourage denials.
  • The utilization process must include systems to monitor for over/under utilization of services. The process shall include analysis or monitoring reports, identification of issues, development of clinical care management plans, and evaluation of the actions.

To discuss a denial, request an appeal, or obtain a copy of the criteria used, please call our Member Services Department at 866-255-4795 (TTY/TDD users should call 866-321-5955). Customer service is available for calls: October 1st – February 14th: 7 days a week, 8:00 a.m. – 8:00 p.m.  February 15th – September 30th: Monday through Friday 8:00 a.m. – 8:00 p.m.  Criteria used for a specific review decision is made available to providers, members and the public upon request to Brand New Day’s Member Services Department.

Leave a Reply

Your email address will not be published. Required fields are marked *