AFFIRMATIVE
STATEMENT
As
a utilization management organization, Physicians DataTrust on behalf of Greater Tri Cities
IPA ensures that all decisions are made
based on the available medical information at the time of the request. Should a
member ask to see the criteria utilized to make a medical decision; the
statement below is attached to that guideline, as required by the National
Committee for Quality Assurance (NCQA):
Decisions regarding
requests for medical care are based on the medical necessity of the request,
the appropriateness of care and service and existence of coverage. There is no
monetary reward for non-approval of services. Compensation for individuals who
provide utilization review services does not contain incentives, direct or
indirect, for these individuals to make inappropriate review decisions.
Utilization review
criteria, based on reasonable medical evidence and acceptable medical standards
of practice (i.e. MCG and/or applicable health plan guidelines) are used to
make decisions pertaining to the utilization of services. Review Criteria are
used in conjunction with the application of professional medical judgment,
which considers the needs of the individual patient and characteristics of the
local delivery system.
IMPARTIALITY
STATEMENT
All
participating practitioners are ensured independence and impartiality in making
referral decisions which will not influence hiring, compensation, termination,
promotion or any other similar matters.
These
statements are also on our websites www.gtcipa.com, along with other
valuable information for our contracted providers and our members, and can be
printed, if needed. Our business hours are Monday through Friday, 9:00a.m. to
5:00p.m. and Administrative staff can be reached at (760) 941-7309 or (800)
458-2307 during business hours. Should you have a question for the Utilization
Management Department after hours, you may call (760) 941-7309 or (800)
458-2307 and leave a message for someone to call you back the next business
day.
