HOW UTILIZATION management WORKS

For most care from specialists, hospitals, skilled nursing facilities, home health agencies or follow up care you must get a referral in advance from your Primary Care Physician (PCP) or your Primary Treating Psychiatrist (PTP). Your PCP or PTP may automatically approve referrals to some specialists and other network providers through a "Direct Referral" but, most referrals to specialists and other network providers require prior approval from Brand New Day. This is called Utilization Management.

AUTHORIZATION FOR SERVICE REQUEST

Your PCP will fill out a form called an "Authorization Service Request Form" and forward it to Brand New Day’s Utilization Management (UM) Department. The UM Department has doctors and other medical personnel who will review the authorization request using Medicare guidelines and other specific criteria (Milliman) for determining medical necessity. Based on the most current information regarding your medical condition and treatment methods a decision is made to either approve or deny the request, or recommend alternative treatments. If a decision cannot be made based upon the medical documentation presented, additional information may be requested before a decision is made.

• UM decision making is based only on appropriateness of care and service and existence of coverage.
• Brand New Day does not specifically reward practitioners or other individuals for issuing denials for coverage of care.
• Financial incentives for UM decision-makers do not encourage decisions that result in under-utilization.

WHEN An AUTHORIZATION REQUEST IS APPROVED

When a requested authorization is approved, you will be referred to the appropriate specialist or other provider within Brand New Day's Contract Network. We will notify your PCP (or PTP) and you of the approval.

WHEN A REFERRAL AUTHORIZATION REQUEST IS DENIED

If Brand New Day decides not to cover services, we will send you a letter explaining why. If you disagree with our decision not to cover services you my file an appeal with Brand New Day. For more information about filing an appeal please refer to your Evidence of Coverage or call Brand New Day Customer Service department at 866-255-4795 and a Customer Service Representative will assist you.