Arizona Complete Health does not reward or incentivize practitioners, providers, or employees who perform utilization reviews (including those involved with delegated entities) for issuing denials of coverage or care. Utilization Management decision making is based only on appropriateness of care, service, and existence of coverage. Utilization Management denials are based on lack of medical necessity or lack of covered benefit.
Arizona Complete Health and its delegated health plan partners have utilization and claims management systems in place to identify, track, and monitor care and to ensure appropriate healthcare is provided to our members.
Arizona Complete Health has implemented the following measures to ensure appropriate utilization of health care:
- A process to monitor for under and overutilization of services and make the appropriate intervention.
- A system to support the analysis of utilization statistics, identification of potential quality of care issues, implementation of intervention plans and evaluation of the effectiveness of actions.
- A process to support continuity of care across the health care continuum.